Search

BACKGROUND The United States has the highest per-capita incarceration rate and the largest prison population in the world. More than two thirds of recently incarcerated individuals will be arrested again within 3 years of release and may commit crimes as serious as homicide soon after discharge. The pattern of homicidal violence currently remains unknown for recently incarcerated homicide suspects (RIHS) and their victims. METHODS A retrospective analysis of the 36 states included in the 2003 to 2017 National Violent Death Reporting System was performed with a focus on RIHS and their victims. Pearson χ2 and Wilcoxon rank sum tests were used for comparison. RESULTS There were 249 RIHS in the database of the 14,561 homicides where suspect recent incarceration status was documented. Compared with not-recently incarcerated suspects, RIHS were more likely to be White (41% vs. 29%, p < 0.001) and male (97% vs. 91%, p < 0.001). Recently incarcerated homicide suspects more often had a known relationship with the victim (75% vs. 51%, p < 0.001), and these homicides more often occurred in the victim's own home (43% vs. 34%, p = 0.006). Intimate partner violence was a factor in 31% of the RIHS cases (vs. 17%, p < 0.001). The homicide weapon was most likely to be a firearm (57.8%, p < 0.001). Only 6.4% of homicides were due to mental health illness. Gang violence, while more common in the RIHS group, was still only a precipitating factor in 12.0% of the homicides (vs. 7.4%, p = 0.006). CONCLUSION Recently incarcerated homicide suspects are more likely to kill a known person in their own home with a firearm, and these homicides are frequently categorized as intimate partner homicides. Gang violence and mental health are not frequent precipitating factors in these deaths. Additional future interventions are urgently needed to eliminate these preventable deaths by alerting previous or current intimate partners of those being discharged from the prison system.

Background Prior studies of venous thromboembolism (VTE) after emergency general surgery (EGS) are not nationally representative nor do they fully capture readmissions to different hospitals. We hypothesized that different-hospital readmission accounted for a significant number of readmissions with VTE after EGS and that predictive factors would be different for same- and different-hospital readmissions. Methods The 2014 Nationwide Readmissions Database was queried for nonelective EGS hospitalizations. The outcomes were readmission to the index or different hospitals within 180 days with VTE. Multivariate logistic regressions identified risk factors for readmission to index and different hospitals with VTE, reported as odds ratios with their 95% confidence intervals. Patients were excluded if during the index admission they expired, developed a VTE, had a vena cava filter placed, or did not have at least 180 days of follow-up. Results Of 1,584,605 patients meeting inclusion criteria, 1.3% (n = 20,963) of patients were readmitted within 180 days with a VTE. Of these, 28% (n = 5,866) were readmitted to a different hospital. Predictors overall for readmission with VTE were malignancy, prolonged hospitalization, age, and being publicly insured. However, predictors for readmission to a different hospital are based on hospital characteristics, including for-profit status, or procedure type. Conclusions Nearly one in three readmissions with VTE after EGS occurs at a different hospital and may be missed by current quality metrics that only capture same-hospital readmission. Such metrics may underestimate for-profit hospital postoperative VTE rates relative to public and nonprofit hospitals, potentially affecting benchmarking and reimbursement. Postdischarge VTE rate is associated with insurance status. These findings have implications for policy and prevention programming design. Level of evidence Epidemiological study, level III.

Background The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively validate ESS, specifically in the high-risk nontrauma emergency laparotomy (EL) patient. Methods This is an Eastern Association for the Surgery of Trauma multicenter prospective observational study. Between April 2018 and June 2019, 19 centers enrolled all adults (aged >18 years) undergoing EL. Preoperative, intraoperative, and postoperative variables were prospectively and systematically collected. Emergency Surgery Score was calculated for each patient and validated using c-statistic methodology by correlating it with three postoperative outcomes: (1) 30-day mortality, (2) 30-day complications (e.g., respiratory/renal failure, infection), and (3) postoperative intensive care unit (ICU) admission. Results A total of 1,649 patients were included. The mean age was 60.5 years, 50.3% were female, and 71.4% were white. The mean ESS was 6, and the most common indication for EL was hollow viscus perforation. The 30-day mortality and complication rates were 14.8% and 53.3%; 57.0% of patients required ICU admission. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. Similarly, ESS gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74. Emergency Surgery Score also accurately predicted which patients required intensive care unit admission (c-statistic, 0.80). Conclusion This is the first prospective multicenter study to validate ESS as an accurate predictor of outcome in the EL patient. Emergency Surgery Score can prove useful for (1) perioperative patient and family counseling, (2) triaging patients to the intensive care unit, and (3) benchmarking the quality of emergency general surgery care. Level of evidence Prognostic study, level III.

BACKGROUND The efficacy of vitamin C (VitC) and thiamine (THMN) in patients admitted to the intensive care unit (ICU) with sepsis is unclear. The purpose of this study was to evaluate the effect of VitC and THMN on mortality and lactate clearance in ICU patients. We hypothesized that survival and lactate clearance would be improved when treated with thiamine and/or VitC. METHODS The Philips eICU database version 2.0 was queried for patients admitted to the ICU in 2014 to 2015 for 48 hours or longer and patients with sepsis and an elevated lactate of 2.0 mmol/L or greater. Subjects were categorized according to the receipt of VitC, THMN, both, or neither. The primary outcome was in-hospital mortality. Secondary outcome was lactate clearance defined as lactate less than 2.0 mmol/L achieved after maximum lactate. Univariable comparisons included age, sex, race, Acute Physiology Score III, Acute Physiology and Chronic Health Evaluation (APACHE) IVa score, Sequential Organ Failure Assessment, surgical ICU admission status, intubation status, hospital region, liver disease, vasopressors, steroids, VitC and THMN orders. Kaplan-Meier curves, logistic regression, propensity score matching, and competing risks modeling were constructed. RESULTS Of 146,687 patients from 186 hospitals, 7.7% (n = 11,330) were included. Overall mortality was 25.9% (n = 2,930). Evidence in favor of an association between VitC and/or THMN administration, and survival was found on log rank test (all p < 0.001). After controlling for confounding factors, VitC (adjusted odds ratio [AOR], 0.69 [0.50-0.95]) and THMN (AOR, 0.71 [0.55-0.93]) were independently associated with survival and THMN was associated with lactate clearance (AOR, 1.50 [1.22-1.96]). On competing risk model VitC (AOR, 0.675 [0.463-0.983]), THMN (AOR, 0.744 [0.569-0.974]), and VitC+THMN (AOR, 0.335 [0.13-0.865]) were associated with survival but not lactate clearance. For subgroup analysis of patients on vasopressors, VitC+THMN were associated with lactate clearance (AOR, 1.85 [1.05-3.24]) and survival (AOR, 0.223 [0.0678-0.735]). CONCLUSION VitC+THMN is associated with increased survival in septic ICU patients. Randomized, multicenter trials are needed to better understand their effects on outcomes. LEVEL OF EVIDENCE Therapeutic Study, Level IV.

Background Unaddressed alcohol use among injured patients may result in recurrent injury or death. Many trauma centers incorporate alcohol screening, brief intervention, and referral to treatment for injured patients with alcohol use disorders, but systematic reviews evaluating the impact of these interventions are lacking. Methods An evidence-based systematic review was performed to answer the following population, intervention, comparator, outcomes question: Among adult patients presenting for acute injury, should emergency department, trauma center, or hospital-based alcohol screening with brief intervention and/or referral to treatment be instituted compared with usual care to prevent or decrease reinjury, hospital readmission, alcohol-related offenses, and/or alcohol consumption? A librarian-initiated query of PubMed, MEDLINE, and the Cochrane Library was performed. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of the evidence and create recommendations. The study was registered with PROSPERO (registration number CRD42019122333). Results Eleven studies met criteria for inclusion, with a total of 1,897 patients who underwent hospital-based alcohol screening, brief intervention, and/or referral to treatment for appropriate patients. There was a relative paucity of data, and studies varied considerably in terms of design, interventions, and outcomes of interest. Overall evidence was assessed as low quality, but a large effect size of intervention was present. Conclusion In adult trauma patients, we conditionally recommend emergency department, trauma center, or hospital-based alcohol screening with brief intervention and referral to treatment for appropriate patients in order to reduce alcohol-related reinjury. Level of evidence Systematic review, Level III.

BACKGROUND A recent Eastern Association for the Surgery of Trauma-supported multicenter trial demonstrated a similar rate of intimate partner and sexual violence (IPSV) between male and female trauma patients, regardless of mechanism. Our objective was to perform a subgroup analysis of our affected male cohort because this remains an understudied group in the trauma literature. METHODS We conducted a recent Eastern Association for the Surgery of Trauma-supported, cross-sectional, multicenter trial over one year (March 2015 to April 2016) involving four Level I trauma centers throughout the United States. We performed universal screening of adult trauma patients using the validated Hurt, Insult, Threaten, Scream and sexual violence screening surveys. Risk factors for male patients were identified. χ Test compared categorical variables with significance at p values less than 0.05. Parametric data are presented as mean ± standard deviation. RESULTS A total of 2,034 trauma patients were screened, of which 1,281 (63%) were men. Of this cohort, 119 (9.3%) men screened positive for intimate partner violence, 14.1% for IPSV, and 6.5% for sexual violence. On categorical analysis of the Hurt, Insult, Threaten, Scream screen, the proportion of men that were physically hurt was 4.8% compared to 4.3% for women (p = 0.896). A total of 4.8% of men screened positive for both IPSV. The total proportion of men who presented with any history of intimate partner violence, sexual violence, or both (IPSV) was 15.8%. More men affected by penetrating trauma screened positive for IPSV (p < 0.00001). The IPSV positivity in men was associated with mental illness, substance abuse, and trauma recidivism. CONCLUSION One of every 20 men that present to trauma centers is a survivor of both IPSV, with one of every six men experiencing some form of violence. Men are at similar risk for physical abuse as women when this intimate partner violence occurs. The IPSV is associated with penetrating trauma in men. Support programs for this population may potentially impact associated mental illness, substance abuse, trauma recidivism, and even societal-level violence. LEVEL OF EVIDENCE Epidemiological study, level II.

Background The length of antimicrobial therapy in complicated intra-abdominal infections (CIAIs) is controversial. A recent prospective, multicenter, randomized controlled trial found that 4 days of antimicrobial therapy after source control of CIAI resulted in similar outcomes when compared with longer duration. We sought to examine whether outcomes remain similar in the subpopulation who received percutaneous drainage for source control of CIAI. Methods With the use of the STOP-IT database, patients with a CIAI who received percutaneous drainage were analyzed. Patients were randomized to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy or to receive a fixed course of antibiotics for 4 ± 1 days. Outcomes included incidence of and time to recurrent intra-abdominal infection, Clostridium difficile infection, and extra-abdominal infections as well as hospital days and mortality. Results Of 518 enrolled patients, 129 met inclusion criteria. Baseline characteristics, including demographics, comorbidities, and severity of illness, were similar. When comparing outcomes of the 4-day group (n = 72) with those of the longer group (n = 57), rates of recurrent intra-abdominal infection (9.7% vs. 10.5%, p = 1.00), C. difficile infection (0% vs. 1.8%, p = 0.442), and hospital days (4.0 [2.0-7.5] vs. 4.0 [3.0-8.0], p = 0.91) were similar. Time to recurrent infection was shorter in the 4-day group (12.7 [6.2] days vs. 21.3 [4.2] days, p = 0.015). There was no mortality. Conclusion In this post hoc analysis of a prospective, multicenter, randomized trial, there was no difference in outcome between a shorter and longer duration of antimicrobial therapy in those with percutaneously drained source control of CIAI. Level of evidence Therapeutic/care management study, level IV.