Trauma and Acute Care Surgery

Commentary on a Case Report, JT-D-19-09465 No abstract available

Screening and Treating Hospitalized Trauma Survivors for PTSD and Depression Traumatic injury affects over 2.6 million U.S. adults annually and elevates risk for a number of negative health consequences. This includes substantial psychological harm, the most prominent being posttraumatic stress disorder (PTSD), with approximately 21% of traumatic injury survivors developing the disorder within the first year after injury. PTSD is associated with deficits in physical recovery, social functioning, and quality of life. Depression is diagnosed in approximately 6% in the year after injury and is also a predictor of poor quality of life. The American College of Surgeons Committee on Trauma suggests screening for and treatment of PTSD and depression, reflecting a growing awareness of the critical need to address patients' mental health needs after trauma. While some trauma centers have implemented screening and treatment or referral for treatment programs, the majority are evaluating how to best address this recommendation and no standard approach for screening and treatment currently exists. Further, guidelines are not yet available with respect to resources that may be used to effectively screen and treat these disorders in trauma survivors, as well as who is going to bear the costs. The purpose of this review is: 1) to evaluate the current state of the literature regarding evidence-based screens for PTSD and depression in the hospitalized trauma patient, and 2) summarize the literature to date regarding the treatments that have empirical support in treating PTSD and depression acutely after injury. This review also includes structural and funding information regarding existing post-injury mental health programs. Screening of injured patients and timely intervention to prevent or treat PTSD and depression could substantially improve health outcomes and improve quality of life for this high-risk population. Level of Evidence Review, level IV Conflicts of Interest and Source of Funding: There are no conflicts of interest to declare and no sources of funding to declare. Corresponding Author: Terri deRoon-Cassini, Ph.D., M.S. (AAST Member) 1Medical College of Wisconsin Department of Surgery Division of Trauma & Acute Care Surgery 8701 Watertown Plank Road Milwaukee, WI 53226 tcassini@mcw.edu © 2019 Lippincott Williams & Wilkins, Inc.

Authors' Response. "Changes in US Mass Shooting Deaths Associated With the 1994-2004 Federal Assault Weapon Ban: Analysis of Open-Source Data." No abstract available

Characteristics of Hardware Failure in Patients Undergoing Surgical Stabilization of Rib Fractures: A Chest Wall Injury Society Multicenter Study Background Surgical stabilization of rib fractures (SSRF) is increasingly used for severe rib fractures/flail chest. There are no reports discussing mechanisms of failure of implanted hardware, its clinical presentation or consequences. The purpose of this study was to evaluate the incidence, presenting signs, and clinical sequela of hardware failure after SSRF. Methods A multicenter, retrospective study was carried out by a group of surgeons with a large SSRF case volume. All cases with known hardware failure from 1/1/2010-12/31/2017 were included. The surgeon's experience at the time of hardware implantation, specific implant used, number of failures the surgeon had experienced with the same system, and time from implantation to hardware failure were recorded. Additionally, patient demographics, including age, co-morbid conditions, and number and location of rib fractures, were recorded. Symptomatology associated with hardware failure and need for explant and/or re-implantation of hardware was also recorded. Non-parametric statistical tests were used to compare cohorts. Results Of 1,224 patients who underwent SSRF, 38 patients with 233 rib fractures and 279 fracture segments experienced hardware failure and were enrolled in the study. Twelve patients presented more than 3 months following injury. Median age was 54 years old and 34% were active smokers. 144 plates were implanted with a median of 4 plates per patient. Median number of SSRF cases by each surgeon was 100 (range 1-280). Fractures and hardware failure were most frequent in the anterolateral/lateral region. Hardware failure was mostly due to screw migration and plate fracture. Hardware failure was asymptomatic in 40% and presented as pain in 42% of cases. 55% of cases required explantation of hardware and only 10% required SSRF again. There was no difference between the acute and chronic fracture cohorts. Conclusion Hardware failure after SSRF is rare and often asymptomatic. When present, it is rarely requires re-do SSRF. Level of evidence Level V, prognostic and epidemiological Corresponding Author: Babak Sarani, MD, FACS, FCCM 2150 Pennsylvania Ave, NW Suite 6B Washington, DC 20037 Email: bsarani@mfa.gwu.edu Rebecca Allen: rebeccaallen@gwmail.gwu.edu Fredric Pieracci: Fredric.Pieracci@dhha.org Andrew Doben: andy@dobenonline.com Evert Eriksson: evert.eriksson@gmail.com Zachary Bauman: zachary.bauman@unmc.edu Puneet Gupta: guptap14@gwmail.gwu.edu Gregory Semon: grsemon@PremierHealth.com Patrick Greiffenstein: pgreif@lsuhsc.edu Alistair Chapman: Alistair.Chapman@spectrumhealth.org Brian Kim: Kim.Brian@mayo.edu Lawrence Lottenberg: lawrence.lottenberg@gmail.com Scott Gardner: Scott.Gardner@imail.org Silvana Marasco: S.Marasco@alfred.org.au Tom White: Tom.White@imail.org Conflicts of interest: Dr. Sarani is a consultant for Acute Innovations Dr. Lottenberg is a consultant for Acute Innovations, Depuy Synthes, and KLS Martin Dr. Doben is a consultant for Zimmer Biomet Dr. Pieracci is a consultant for Depuy Synthes and has received research funding from DePuy Synthes Dr. Greiffenstein is a consultant for Zimmer Biomet and Depuy Synthes Drs. White and Chapman are consultants for Depuy Synthes and KLS Martin Dr. Marasco is a consultant for Depuy Synthes Drs. Kim, Bauman, Semon, and Eriksson, Ms. Allen, and Mr. Gupta and Gardner do not have any conflicts of interest to disclose This was an oral presentation at the annual Chest Wall Injury Society Summit in Santa Fe, NM in March 2019. Funding source: none © 2019 Lippincott Williams & Wilkins, Inc.

Top-Tier Emergency General Surgery Hospitals: Good at One Operation, Good at Them All Background There is a longstanding interest in the field of management science to study high performance organizations. Applied to medicine, research on hospital performance indicates that some hospitals are high performing, while others are not. The objective of this study was to identify a cluster of high performing emergency general surgery (EGS) hospitals and assess whether high performance at one EGS operation was associated with high performance on all EGS operations. Methods Adult patients who underwent 1 of 8 EGS operations were identified in the California State Inpatient Database (2010-2011), which we linked to the American Hospital Association database. Beta regression was used to estimate a hospital's risk-adjusted mortality, accounting for patient- and hospital-level factors. Centroid cluster analysis grouped hospitals by pattern of mortality rates across the 8 EGS operations using z-scores. Multinomial logistic regression compared hospital characteristics by cluster. Results A total of 220 acute care hospitals were included. Three distinct clusters of hospitals were defined based on assessment of mortality for each operation type: high performing hospitals (n=66), average performing (n=99), and low performing (n=55). The mortality by individual operation type at the high performing cluster was consistently at least 1.5 standard deviations better than the low performing cluster (p<0.001). Within-cluster variation was minimal at high performing hospitals compared to wide variation at low performing hospitals. A hospital's high performance in one EGS operation type predicted high performance on all EGS operation types. Conclusions High performing EGS hospitals attain excellence across all types of EGS operations, with minimal variability in mortality. Poor performing hospitals are persistently below average, even for low-risk operations. These findings suggest that top-performing EGS hospitals are highly reliable, with systems of care in place to achieve consistently superior results. Further investigation and collaboration are needed to identify the factors associated with high performance. Level of Evidence Level III, Study Type Prognostic For Correspondence and Reprints: Robert D. Becher, MD MS, Department of Surgery, Section of General Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, 330 Cedar Street, BB 310, New Haven, CT 06520, Email: robert.becher@yale.edu Support: Dr. Becher acknowledges that this publication was made possible by the support of: the Yale Center for Clinical Investigation CTSA Grant Number KL2 TR001862 from the National Center for Advancing Translational Science (NCATS), a component of the National Institutes of Health (NIH); and the American Association for the Surgery of Trauma (AAST) Emergency General Surgery Research Scholarship Award. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the AAST or the NIH. Dr. Gill acknowledges the support of the Academic Leadership Award (K07AG043587) and Claude D. Pepper Older Americans Independence Center (P30AG021342) from the National Institute on Aging. Conflicts of Interest: No competing financial interests exist. Presented at: The 77th Annual Meeting of the American Association for the Surgery of Trauma September 26th-29th, 2018, San Diego, CA © 2019 Lippincott Williams & Wilkins, Inc.

Systematic Reviews of Scores and Predictors to Trigger Activation of Massive Transfusion Protocols Background The use of massive transfusion protocols (MTPs) in the resuscitation of hemorrhaging trauma patients ensures rapid delivery of blood products to improve outcomes, where the decision to trigger MTPs early is important. Scores and tools to predict the need for MTP activation have been developed for use to aid with clinical judgement. We performed a systematic review to assess 1) the scores and tools available to predict MTP in trauma patients, 2) their clinical value and diagnostic accuracies, and 3) additional predictors of MTP. Methods MEDLINE, EMBASE, and CENTRAL were searched from inception to June 2017. All studies that utilized scores or predictors of MTP activation in adult (age ≥18) trauma patients were included. Data collection for scores and tools included reported sensitivities and specificities and accuracy as defined by the area under the curve of the receiver operating characteristic (AUROC). Results 45 articles were eligible for analysis, with eleven validated and four unvalidated scores and tools assessed. Of four scores using clinical assessment, laboratory values, and ultrasound assessment the modified Traumatic Bleeding Severity Score (TBSS) had the best performance. Of those scores, the Trauma Associated Severe Hemorrhage (TASH) score is most well validated and has higher AUROC than the Assessment of Blood Consumption (ABC) and Prince of Wales (PWH) scores. Without laboratory results, the ABC score balances accuracy with ease of use. Without ultrasound use, the Vandromme and Schreiber scores have the highest accuracy and sensitivity respectively. The Shock Index (SI) uses clinical assessment only with fair performance. Other clinical variables, laboratory values, and use of point-of-care testing results were identified predictors of MTP activation. Conclusion The use of scores or tools to predict MTP need to be individualized to hospital resources and skill set to aid clinical judgement. Future studies for triggering non-trauma MTP activations are needed. Study Type Systematic Review Level of Evidence Level III Evidence, Prognostic Authors contributed equally to the work, Andrew W. Shih, Shadhiya Al Khan Corresponding Author: Andrew Shih, MD, FRCPC, DRCPSC, MSc, Vancouver General Hospital, Department of Pathology, JPP1, room 1553, 855 West 12th Avenue, Vancouver, B.C. V5Z 1M9, Phone: (604) 875-4111 Ext. 61109, e-mail: andrew.shih@medportal.ca Conflicts of Interest: A.W.S. is a consultant for Octapharma Canada. The contents of this manuscript have not been presented at any scientific meetings. © 2019 Lippincott Williams & Wilkins, Inc.

Impact of the Affordable Care Act on Trauma and Emergency General Surgery: An Eastern Association for the Surgery of Trauma Systematic Review and Meta-Analysis Background Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared to insured patients. Partially modelled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act (ACA) was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. Methods This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using GRADE methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. Results From 4,593 citations, we found 18 studies addressing all 7 predefined outcomes of interest for trauma patients, 3 studies addressing 6 of 7 outcomes for EGS patients, and 3 studies addressing 3 of 8 outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (OR 0.49; 95% CI, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (OR 0.96; 95% CI, 0.88–1.05). EGS patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to post-acute care at discharge. The evidence for trauma systems was heterogeneous. Conclusions Given the evidence quality we conditionally recommend ME/MHR to improve insurance coverage and access to post-acute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. Level of Evidence Level III Study Type Review, Economic/Decision Corresponding author: Marie Crandall, MD, MPH, FACS, 655 W. 8th Street, Jacksonville, FL 32209, marie.crandall@jax.ufl.edu © 2019 Lippincott Williams & Wilkins, Inc.

Surgery For Adhesive Small Bowel Obstruction Is Associated With Improved Long-Term Survival Mediated Through Recurrence Prevention: A Population-Based, Propensity-Matched Analysis Background Adhesive small bowel obstruction (aSBO) is among the most common reasons for admission to a surgical service. While operative intervention for aSBO is associated with a lower risk of recurrence, current guidelines continue to advocate a trial of non-operative management. The impact of the increased risk for recurrence on long-term survival is unknown. We sought to explore the potential for improved survival with operative management through the prevention of admissions for recurrence of aSBO and the associated risks. Methods This is a population-based retrospective cohort study using administrative data. We identified patients admitted to hospital for their first episode of aSBO from 2005-2014 and created a propensity-matched cohort to compare survival of patients managed operatively to those managed non-operatively. To test whether survival differences were mediated by recurrence prevention, a competing risk regression was used to model the sub-distribution hazard of death when accounting for the risk of recurrence. An instrumental variable approach was used as a secondary analysis to compare survival while accounting for unmeasured confounding. Results 27,904 patients were admitted for their first episode of aSBO between 2005-2014. The mean age was 61.2 years (std dev:13.6) and 51% were female. Operative management was associated with a significantly lower risk of death (HR:0.80, 95%CI:0.75-0.86), which was robust to instrumental variable analyses, and a lower risk of recurrence (HR:0.59, 95%CI:0.54-0.65). When adjusting for the risk of recurrence, operative intervention was not associated with improved survival, suggesting that the survival benefit is mediated through prevention of recurrences of aSBO. Conclusion In patients admitted for their first episode of aSBO, operative intervention is associated with a significant long-term survival benefit. This survival benefit appears to be mediated through the prevention of recurrences of aSBO. Study Type Retrospective cohort study Level of Evidence Level II Correspondence & Reprints: Paul Karanicolas, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, T2-016, Toronto ON, M4N 3M5, (416) 480-4774, paul.karanicolas@sunnybrook.ca Sources of Support: Physician Services Incorporated Resident Research Grant, Ministry of Health and Long-term Care Clinician Investigator Program, Conflicts of Interest: None. © 2019 Lippincott Williams & Wilkins, Inc.

FAILURE TO RESCUE IN SURGICAL PATIENTS: A REVIEW FOR ACUTE CARE SURGEONS The Failure to Rescue (FTR) rate is defined as the mortality rate among patients who experience one or more complications. It has been used as an outcome metric for approximately 25 years, primarily in elective surgery populations, and has been shown to be associated with factors that are modifiable on the institutional level. Although the FTR metric was derived in elective surgical populations, modifications have been made in attempts to refine the metric and apply it to broader populations, including medical patients and non-elective surgical patients. However, study among emergency general surgery patients has been limited. In this review, we summarize the current knowledge surrounding FTR, including established risk factors and potential limitations of the metric in emergency general surgery (EGS) populations. We then discuss a conceptual model for FTR events and review strategies to minimize rates. Finally, we provide a brief overview of current areas of study and potential future directions in acute care surgery. Study Type Review article Corresponding author and requests for reprint requests: Justin Hatchimonji, MD MBE, Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce St, 4 Maloney, Cell: 267-408-5825, justin.hatchimonji@uphs.upenn.edu Conflicts of Interest and Source of Funding: No authors have conflicts to declare. DNH is currently supported by a training grant through the National Heart, Lung, and Blood Institute. (K08HL131995) © 2019 Lippincott Williams & Wilkins, Inc.

Answer: Letter of the Editor Management of Devastating Duodenal Injuries No abstract available

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