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BACKGROUND: Advances in medical technology have widened the gaps and exposed disparities in medical treatments. The prevalence of surgical stabilization for rib fractures is rising despite its controversial indications for this treatment modality. In situations of equipoise, surgeons may find themselves choosing patients for surgery, revealing potential implicit biases. We hypothesize that there exists an inequity in surgical stabilization for rib fractures performed based on race. METHODS: Data were obtained from the American College of Surgeons 2013-2021 Trauma Quality Improvement Program database. Study participants were divided into race groups according to Trauma Quality Improvement Program data registry. To assess the association between race and surgical stabilization for rib fractures, a Poisson regression model was used. Potential confounding adjusted include race, age, sex, highest abbreviated injury severity score in each region, flail chest, sternum fracture, pneumothorax, hemothorax, pulmonary contusion, and comorbidities. RESULT: Black patients were more often treated at a level 1 trauma center (74%) (P < .001). Flail chest was most common in White (3.2%) and American Indian (3.4%) patients compared with other races (P = .012). After adjusting for potential confounding in the Poisson regression analyses, Black patients were 26% less likely to undergo surgical stabilization for rib fractures (adjusted incident rate ratio [95% confidence interval]: 0.74 [0.64-0.85], P < .001) and Asian were 40% less likely to undergo surgical stabilization for rib fractures (adjusted incident rate ratio [95% confidence interval]: 0.60 [0.43-0.81], P = .001) than White patients. CONCLUSION: There is a disparity in the delivery of surgical stabilization for rib fractures in patients with rib fractures. Black and Asian patients undergo surgical stabilization for rib fractures at a significantly lower rate than their White counterparts. This discrepancy in the delivery

OBJECTIVES: Rib fractures are common, morbid, and potentially lethal. Intuitively, if interventions to mitigate downstream effects of rib fractures can be implemented early, likelihood of developing these complications should be reduced. Surgical stabilization of rib fractures (SSRF) is one therapeutic intervention shown to be useful for mitigating complications of these common fractures. Our aim was to investigate for association between time to SSRF and complications among patients with isolated rib fractures undergoing SSRF. METHODS: The 2016-2019 American College of Surgeons Trauma Quality Improvement Program (TQIP) database was queried to identify patient >18 years with isolated thoracic injury undergoing SSRF. Patients were divided into three groups: SSRF ≤2 days, SSRF >2 days but <3 days, and SSRF >3 days. Poisson regression, and adjusting for demographic and clinical covariates, was used to evaluate the association between time to SSRF and the primary endpoint, in-hospital complications. Quantile regression was used to evaluate the effects of time to SSRF on the secondary endpoints, hospital and intensive care unit (ICU) length of stay (LOS). RESULTS: Out of 2185 patients, 918 (42%) underwent SSRF <2 days, 432 (20%) underwent SSRF >2 days but <3 days, and 835 (38%) underwent SSRF >3 days. Hemothorax was more common among patients undergoing SSRF >3 days, otherwise all demographic and clinical variables were similar between groups. After adjusting for potential confounding, SSRF >3 days was associated with a threefold risk of composite in-hospital complications (adjusted incidence rate ratio: 3.15, 95% CI 1.76 to 5.62; p<0.001), a 4-day increase in total hospital LOS (change in median LOS: 4.09; 95% CI 3.69 to 4.49, p<0.001), and a nearly 2-day increase in median ICU LOS (change in median LOS: 1.70; 95% CI 1.32 to 2.08, p<0.001), compared with SSRF ≤2 days. CONCLUSION: Among patients undergoing SSRF in TQIP, earlier SSRF

BACKGROUND: With an aging global population, the prevalence of frailty in patients with traumatic spinal injury (TSI) is steadily increasing. The aim of the current study is to evaluate the utility of the Orthopedic Frailty Score (OFS) in assessing the risk of adverse outcomes in patients with isolated TSI requiring surgery, with the hypothesis that frailer patients suffer from a disproportionately increased risk of these outcomes. METHODS: The Trauma Quality Improvement Program database was queried for all adult patients (18 years or older) who suffered an isolated TSI due to blunt force trauma, between 2013 and 2019, and underwent spine surgery. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The association between the OFS and in-hospital mortality, complications, and failure to rescue (FTR) was determined using Poisson regression models, adjusted for potential confounding. RESULTS: A total of 43 768 patients were included in the current investigation. After adjusting for confounding, frailty was associated with a more than doubling in the risk of in-hospital mortality (adjusted incidence rate ratio (IRR) (95% CI): 2.53 (2.04 to 3.12), p<0.001), a 25% higher overall risk of complications (adjusted IRR (95% CI): 1.25 (1.02 to 1.54), p=0.032), a doubling in the risk of FTR (adjusted IRR (95% CI): 2.00 (1.39 to 2.90), p<0.001), and a 10% increase in the risk of intensive care unit admission (adjusted IRR (95% CI): 1.10 (1.04 to 1.15), p=0.004), compared with non-frail patients. CONCLUSION: The findings indicate that the OFS could be an effective method for identifying frail patients with TSIs who are at a disproportionate risk of adverse events. LEVEL OF EVIDENCE: Level III.

INTRODUCTION: The number of patients with hip fractures continues to rise as the average age of the population increases. Optimizing outcomes in this cohort is predicated on timely operative repair. The aim of this study was to determine if patients with hip fractures who are frail or have a higher cardiac risk suffer from an increased risk of in-hospital mortality when surgery is postponed >24 h. METHODS: All patients registered in the 2013-2021 TQIP dataset who were ≥65 years old and underwent surgical fixation of an isolated hip fracture caused by a ground-level fall were included. Adjustment for confounding was performed using inverse probability weighting (IPW) while stratifying for frailty with the Orthopedic Frailty Score (OFS) and cardiac risk using the Revised Cardiac Risk Index (RCRI). The outcome was presented as the absolute risk difference in in-hospital mortality. RESULTS: A total of 254,400 patients were included. After IPW, all confounders were balanced. A delay in surgery was associated with an increased risk of in-hospital mortality across all strata, and, as the degree of frailty and cardiac risk increased, so too did the risk of mortality. In patients with OFS ≥4, delaying surgery >24 h was associated with a 2.33 percentage point increase in the absolute mortality rate (95% CI: 0.57-4.09, p = 0.010), resulting in a number needed to harm (NNH) of 43. Furthermore, the absolute risk of mortality increased by 4.65 percentage points in patients with RCRI ≥4 who had their surgery delayed >24 h (95% CI: 0.90-8.40, p = 0.015), resulting in a NNH of 22. For patients with OFS 0 and RCRI 0, the corresponding NNHs when delaying surgery >24 h were 345 and 333, respectively. CONCLUSION: Delaying surgery beyond 24 h from admission increases the risk of mortality for all geriatric hip fracture patients. The magnitude of the negative impact increases with the patient's level of cardiac risk and frailty. Operative intervention should not be delayed bas

BACKGROUND: Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures. METHODS: All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding. RESULTS: A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001]. CONCLUSION: There is a strong association between frailty, measured using the OFS, and a

INTRODUCTION: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries. METHODS: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding. RESULTS: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score. CONCLUSION: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

Objective: Nearly 7% of the adult US population has symptomatic Attention Deficit Hyperactivity Disorder (ADHD), which is associated with an increased risk for traumatic injury. There is limited data on the outcome of hospitalized trauma patients with ADHD. This study aimed to use a large nationwide database to investigate the relationship between a diagnosis of ADHD and clinical outcomes in hospitalized patients after major trauma. Methods: All patients 18 years or older in the National Trauma Database were retrospectively reviewed. Propensity score analysis was used to match patients with and without the diagnosis of ADHD at a 1:1 ratio based on age, sex, race, highest AIS in each region, comorbidities, and the presence of advanced directives limiting care. Outcomes of patients with ADHD admitted to the trauma service between the years 2015 and 2017 were compared to those without ADHD. The primary outcome of interest was in-hospital mortality, while the secondary outcomes included complications and hospital length of stay. Results: There were 9399 patients included in the study with a diagnosis of ADHD. These patients were overall more likely to be younger, male, and Caucasian, compared to their matched counterparts without ADHD. ADHD was associated with a significantly lower in-hospital mortality than patients without ADHD. There was no difference in the ICU admission rate, ICU LOS, ventilator use, or complication rates between patients with and without ADHD. Conclusion: A diagnosis of ADHD has a complex association with clinical outcomes after trauma. The current large national analysis found that patients with a diagnosis of ADHD had significantly lower overall in-hospital mortality.

BACKGROUND: Traumatic spinal injury (TSI) encompasses a wide range of injuries affecting the spinal cord, nerve roots, bones, and soft tissues that result in pain, impaired mobility, paralysis, and death. There is some evidence suggesting that women may have different physiological responses to traumatic injury compared to men; therefore, this study aimed to investigate if there are any associations between sex and adverse outcomes following surgically managed isolated TSI. METHODS: Using the 2013-2019 TQIP database, all adult patients with isolated TSI, defined as a spine AIS ≥ 2 with an AIS ≤ 1 in all other body regions, resulting from blunt force trauma requiring spinal surgery, were eligible for inclusion in the study. The association between the sex and in-hospital mortality as well as cardiopulmonary and venothromboembolic complications was determined by calculating the risk ratio (RR) after adjusting for potential confounding using inverse probability weighting. RESULTS: A total of 43,756 patients were included. After adjusting for potential confounders, female sex was associated with a 37% lower risk of in-hospital mortality [adjusted RR (95% CI): 0.63 (0.57-0.69), p < 0.001], a 27% lower risk of myocardial infarction [adjusted RR (95% CI): 0.73 (0.56-0.95), p = 0.021], a 37% lower risk of cardiac arrest [adjusted RR (95% CI): 0.63 (0.55-0.72), p < 0.001], a 34% lower risk of deep vein thrombosis [adjusted RR (95% CI): 0.66 (0.59-0.74), p < 0.001], a 45% lower risk of pulmonary embolism [adjusted RR (95% CI): 0.55 (0.46-0.65), p < 0.001], a 36% lower risk of acute respiratory distress syndrome [adjusted RR (95% CI): 0.64 (0.54-0.76), p < 0.001], a 34% lower risk of pneumonia [adjusted RR (95% CI): 0.66 (0.60-0.72), p < 0.001], and a 22% lower risk of surgical site infection [adjusted RR (95% CI): 0.78 (0.62-0.98), p < 0.032], compared to male sex. CONCLUSION: Female sex is associated with a significantly decreased risk of in-hospital mor

INTRODUCTION: Early tracheostomy (ET) is associated with a lower incidence of pneumonia (PNA) and mechanical ventilation duration (MVD) in hospitalized patients with trauma. The purpose of this study is to determine if ET also benefits older adults compared to the younger cohort. METHODS: Adult hospitalized trauma patients who received a tracheostomy as registered in The American College of Surgeons Trauma Quality Improvement Program from 2013 to 2019 were analyzed. Patients with tracheostomy prior to admission were excluded. Patients were stratified into 2 cohorts consisting of those aged ≥65 and those aged <65. These cohorts were analyzed separately to compare the outcomes of ET (<5 d; ET) versus late tracheostomy (LT) (≥5 d; LT). The primary outcome was MVD. Secondary outcomes were in-hospital mortality, hospital length of stay (HLOS), and PNA. Univariate and multivariate analyses were performed with significance defined as P value < 0.05. RESULTS: In patients aged <65, ET was performed within a median of 2.3 d (interquartile range, 0.47-3.8) after intubation and a median of 9.9 d (interquartile range, 7.5-13) in the LT group. The ET group's Injury Severity Score was significantly lower with fewer comorbidities. There were no differences in injury severity or comorbidities when comparing the groups. ET was associated with lower MVD (d), PNA, and HLOS on univariate and multivariate analyses in both age cohorts, although the degree of benefit was higher in the less than 65 y cohort [ET versus LT MVD: 5.08 (4.78-5.37), P < 0.001; PNA: 1.45 (1.36-1.54), P < 0.001; HLOS: 5.48 (4.93-6.04), P < 0.001]. Mortality did not differ based on time to tracheostomy. CONCLUSIONS: ET is associated with lower MVD, PNA, and HLOS in hospitalized patients with trauma regardless of age. Age should not factor into timing for tracheostomy placement.

Introduction: Pelvic fractures among the elderly are associated with an increased risk of adverse outcomes. Frailty, a condition of depleted physical reserves which increases with age, is likely a contributing factor for such unfavorable events. We endeavored to describe the association between frailty, measured using the Ortho-pedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients. Methods: All geriatric (≥65yrs) patients registered in the 2013 to 2019 TQIP database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the ilium, ischium, pubis, sacrum, coccyx, or acetabulum with an AIS ≤1 in all other regions except for abdominal and lower extremity. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). Poisson regression models were employed to determine the association between the OFS and adverse outcomes adjusting for confounders including angiographical and surgical interventions. Results: A total of 66,404 patients met inclusion criteria, of whom 52% were classified as non-frail, 32% as pre-frail, and 16% as frail. Compared to non-frail patients, frail patients exhibited 88% increased risk of in-hospital mortality [adjusted IRR (95% CI): 1.88 (1.54-2.30), p<0.001], a 25% increased risk of composite complications [adjusted IRR (95% CI): 1.25 (1.10-1.42), p<0.001], a 56% increased risk of failure to rescue [adjusted IRR (95% CI): 1.56 (1.14-2.14), p=0.006]. Conclusion: Frail geriatric patients suffering a pelvic fracture have disproportionately increased risk for complications, mortality, and failure-to-rescue. Additional measures are required to mitigate adverse events in this vulnerable population.

BACKGROUND: Existing study findings on firearms-related injury patterns are largely skewed towards males, who comprise the majority of this injury population. Given the paucity of existing data for females with these injuries, we aimed to elucidate the demographics, injury patterns, and outcomes of firearms-related injury in females compared with males in the USA. MATERIALS AND METHODS: A 7-year (2013-2019) retrospective review of the National Trauma Database was conducted to identify all adult patients who suffered firearms-related injuries. Patients who were males were matched (1:1, caliper 0.2) to patients who were females by demographics, comorbidities, injury patterns and severity, and payment method, to compare differences in mortality and several other post-injury outcomes. RESULTS: There were 196 696 patients admitted after firearms-related injury during the study period. Of these patients, 23 379 (11.9%) were females, 23 378 of whom were successfully matched to a male counterpart. After matching, females had a lower rate of in-hospital mortality (18.6% vs. 20.0%, p<0.001), deep vein thrombosis (1.2% vs. 1.5%, p=0.014), and had a lower incidence of drug or alcohol withdrawal syndrome (0.2% vs. 0.5%, p<0.001) compared with males. CONCLUSION: Female victims of firearms-related injuries experience lower rates of mortality and complications compared with males. Further studies are needed to elucidate the cause of these differences. LEVEL OF EVIDENCE: Level III.

INTRODUCTION: The elderly population constitutes one of the fastest-growing demographic groups globally. Within this population, mild to moderate traumatic brain injuries (TBI) resulting from ground level falls (GLFs) are prevalent and pose significant challenges. Between 50 and 80% of TBIs in older individuals are due to GLFs. These incidents result in more severe outcomes and extended recovery periods for the elderly, even when controlling for injury severity. Given the increasing incidence of such injuries it becomes essential to identify the key factors that predict complications and in-hospital mortality. Therefore, the aim of this study was to pinpoint the top predictors of complications and in-hospital mortality in geriatric patients who have experienced a moderate TBI following a GLF. METHODS: Data were obtained from the American College of Surgeons' Trauma Quality Improvement Program database. A moderate TBI was defined as a head AIS ≤ 3 with a Glasgow Coma Scale (GCS) 9-13, and an AIS ≤ 2 in all other body regions. Potential predictors of complications and in-hospital mortality were included in a logistic regression model and ranked using the permutation importance method. RESULTS: A total of 7,489 patients with a moderate TBI were included in the final analyses. 6.5% suffered a complication and 6.2% died prior to discharge. The top five predictors of complications were the need for neurosurgical intervention, the Revised Cardiac Risk Index, coagulopathy, the spine abbreviated injury severity scale (AIS), and the injury severity score. The top five predictors of mortality were head AIS, age, GCS on admission, the need for neurosurgical intervention, and chronic obstructive pulmonary disease. CONCLUSION: When predicting both complications and in-hospital mortality in geriatric patients who have suffered a moderate traumatic brain injury after a ground level fall, the most important factors to consider are the need for neurosurgical intervention, cardiac ris

Introduction: Pelvic fractures among the elderly are associated with an increased risk of adverse outcomes. Frailty, a condition of depleted physical reserves which increases with age, is likely a contributing factor for such unfavorable events. We endeavored to describe the association between frailty, measured using the Ortho-pedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients. Methods: All geriatric (≥65yrs) patients registered in the 2013 to 2019 TQIP database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the ilium, ischium, pubis, sacrum, coccyx, or acetabulum with an AIS ≤1 in all other regions except for abdominal and lower extremity. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). Poisson regression models were employed to determine the association between the OFS and adverse outcomes adjusting for confounders including angiographical and surgical interventions. Results: A total of 66,404 patients met inclusion criteria, of whom 52% were classified as non-frail, 32% as pre-frail, and 16% as frail. Compared to non-frail patients, frail patients exhibited 88% increased risk of in-hospital mortality [adjusted IRR (95% CI): 1.88 (1.54-2.30), p<0.001], a 25% increased risk of composite complications [adjusted IRR (95% CI): 1.25 (1.10-1.42), p<0.001], a 56% increased risk of failure to rescue [adjusted IRR (95% CI): 1.56 (1.14-2.14), p=0.006]. Conclusion: Frail geriatric patients suffering a pelvic fracture have disproportionately increased risk for complications, mortality, and failure-to-rescue. Additional measures are required to mitigate adverse events in this vulnerable population.

BACKGROUND: Traumatic brain injury (TBI) represents a significant global health issue; the traditional tools such as the Glasgow Coma Scale (GCS) and Abbreviated Injury Scale (AIS) which have been used for injury severity grading, struggle to capture outcomes after TBI. AIM AND METHODS: This paper aims to implement extreme gradient boosting (XGBoost), a powerful machine learning algorithm that combines the predictions of multiple weak models to create a strong predictive model with high accuracy and efficiency, in order to develop and validate a predictive model for in-hospital mortality in patients with isolated severe traumatic brain injury and to identify the most influential predictors. In total, 545,388 patients from the 2013-2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) database were included in the current study, with 80% of the patients used for model training and 20% of the patients for the final model test. The primary outcome of the study was in-hospital mortality. Predictors were patients' demographics, admission status, as well as comorbidities, and clinical characteristics. Penalized Cox regression models were used to investigate the associations between the survival outcomes and the predictors and select the best predictors. An extreme gradient boosting (XGBoost)-powered Cox regression model was then used to predict the survival outcome. The performance of the models was evaluated using the Harrell's concordance index (C-index). The time-dependent area under the receiver operating characteristic curve (AUC) was used to evaluate the dynamic cumulative performance of the models. The importance of the predictors in the final prediction model was evaluated using the Shapley additive explanations (SHAP) value. RESULTS: On average, the final XGBoost-powered Cox regression model performed at an acceptable level for patients with a length of stay up to 250 days (mean time-dependent AUC = 0.713) in the test dataset. However, for p

PURPOSE: Pelvic fractures among older adults are associated with an increased risk of adverse outcomes, with frailty likely being a contributing factor. The current study endeavors to describe the association between frailty, measured using the Orthopedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients. METHODS: All geriatric (65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement Program database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the pelvis with a lower extremity AIS ≥ 2, any abdomen AIS, and an AIS ≤ 1 in all other regions. Poisson regression models were employed to determine the association between the OFS and adverse outcomes. RESULTS: A total of 66,404 patients were included for further analysis. 52% (N = 34,292) were classified as non-frail (OFS 0), 32% (N = 21,467) were pre-frail (OFS 1), and 16% (N = 10,645) were classified as frail (OFS ≥ 2). Compared to non-frail patients, frail patients exhibited a 88% increased risk of in-hospital mortality [adjusted IRR (95% CI): 1.88 (1.54-2.30), p < 0.001], a 25% increased risk of complications [adjusted IRR (95% CI): 1.25 (1.10-1.42), p < 0.001], a 56% increased risk of failure-to-rescue [adjusted IRR (95% CI): 1.56 (1.14-2.14), p = 0.006], and a 10% increased risk of ICU admission [adjusted IRR (95% CI): 1.10 (1.02-1.18), p = 0.014]. CONCLUSION: Frail pelvic fracture patients suffer from a disproportionately increased risk of mortality, complications, failure-to-rescue, and ICU admission. Additional measures are required to mitigate adverse events in this vulnerable patient population.

BACKGROUND: Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture. METHODS: All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders. RESULTS: 96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome. CONCLUSIONS: Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.

BACKGROUND: The Brain Trauma Foundation recommends intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (TBI). Race is associated with worse outcomes after TBI. The reasons for racial disparities in clinical decision-making around ICP monitor placement remain unclear. STUDY DESIGN: We queried the TQIP database from 2017 to 2019 and included patients 16 years or older, with blunt severe TBI, defined as a head abbreviated injury score 3 or greater. Exclusion criteria were missing race, those without signs of life on admission, length of stay 1 day or less, and AIS of 6 in any body region. The primary outcome was ICP monitor placement, which was calculated using a Poisson regression model with robust SEs while adjusting for confounders. RESULTS: A total of 260,814 patients were included: 218,939 White, 29,873 Black, 8,322 Asian, 2,884 American Indian, and 796 Native Hawaiian or Other Pacific Islander. Asian and American Indian patients had the highest rates of midline shift (16.5% and 16.9%). Native Hawaiian or Other Pacific Islanders had the highest rates of neurosurgical intervention (19.3%) and ICP monitor placement (6.5%). Asian patients were found to be 19% more likely to receive ICP monitoring (adjusted incident rate ratio 1.19; 95% CI 1.06 to 1.33; p = 0.003], and American Indian patients were 38% less likely (adjusted incident rate ratio 0.62; 95% CI 0.49 to 0.79; p < 0.001), compared with White patients, respectively. No differences were detected between White and Black patients. CONCLUSIONS: ICP monitoring use differs by race. Further work is needed to elucidate modifiable causes of this difference in the management of severe TBI.

BACKGROUND: Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients. METHODS: We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16 years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1 day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders. RESULTS: A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed. DISCUSSION: While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.

BACKGROUND: Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute care setting. Consequently, this systematic review and network meta-analysis, comparing one-stage (CBD exploration or intraoperative endoscopic retrograde cholangiopancreatography [ERCP] with simultaneous cholecystectomy) and two-stage (precholecystectomy or postcholecystectomy ERCP) procedures, was undertaken with the main outcomes of interest being postprocedural complications and hospital length of stay (LOS). METHODS: PubMed, SCOPUS, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were methodically queried for articles from 2010 to 2021. The search terms were a combination of medical subject headings terms and the subsequent terms: gallstone; common bile duct (stone); choledocholithiasis; cholecystitis; endoscopic retrograde cholangiography/ERCP; common bile duct exploration; intraoperative, preoperative, perioperative, and postoperative endoscopic retrograde cholangiography: stone extraction; and one-stage and two-stage procedure. Studies that compared two procedures or more were included, whereas studies not recording complications (bile leak, hemorrhage, pancreatitis, perforation, intra-abdominal infections, and other infections) or LOS were excluded. A network meta-analysis was conducted to compare the four different approaches for managing CBD stones. RESULTS: A total of 16 studies (8,644 participants) addressing the LOS and 41 studies (19,756 participants) addressing postprocedural complications were included in the analysis. The one-stage approaches were associated with a decrease in LOS compared with the two-stage approaches. Common bile duct exploration demonstrated a lower overall risk of complications compared with preoperative ERCP, but there were no differences in the overall risk orcomplications in the remaining comparisons. However, differences in spec

Introduction: The Brain Trauma Foundation recommends intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (TBI). Race is associated with worse outcomes after TBI. The reasons for racial disparities in clinical decision-making around ICP monitor placement remain unclear. Methods: We queried the Trauma Quality Improvement Project (TQIP) database from 2017-2019 and included patients ≥16 years old, with blunt severe TBI. Exclusion criteria was no recorded race, those without signs of life, had length of stay <1 day and AIS=6 in any body region. Variables included demographic, clinical, and outcome characteristics. The primary outcome was probability of ICP-monitor placement. We calculated incidence rate ratios for ICP monitor placement using a Poisson regression model to adjust for confounders. Results: A total of 260,814 patients were included: 218,939 White, 29,873 Black, 8,322 Asian, 2,884 Native American, and 796 Pacific Islander. Asian and Native American patients had the highest rates of midline shift (16.5% and 16.9%). Pacific Islanders had the highest rates of neurosurgical intervention (19.3%) and ICP monitor placement (6.5%). Asian patients were found to be 19% more likely to receive ICP monitoring [adjusted IRR 1.19 (95%CI: 1.06-1.33), p = 0.003], while Native American patients were 38% less likely [adjusted IRR 0.62 (95%CI: 0.49-0.79), p < 0.001], compared with White patients, respectively. No differences were detected between White and Black patients. Conclusion: ICP monitoring use differs significantly by race. Further work is needed to elucidate modifiable causes of this difference in the management of severe TBI.

BACKGROUND: Blood-based balanced resuscitation is a standard of care in massively bleeding trauma patients. No data exists as to when this therapy no longer significantly affects mortality. We sought to determine if there is a threshold beyond which further massive transfusion will not affect in-hospital mortality. METHODS: The Trauma Quality Improvement database was queried for all adult patients registered between 2013 and 2017 who received at least one unit of blood (PRBC) within 4 hours of arrival. In-hospital mortality was evaluated based on the total transfusion volume (TTV) at 4 and 24 hours in the overall cohort (OC) and in a balanced transfusion cohort (BC), composed of patients who received transfusion at a ratio of 1:1-2:1 PRBC-to-plasma. A bootstrapping method in combination with multivariable Poisson regression (MVR) was used to find a cutoff after which additional transfusion no longer affected in-hospital mortality. MVR was used to control for age, sex, race, highest abbreviated injury score in each body region, comorbidities, advanced directives limiting care, and the primary surgery performed for hemorrhage control. RESULTS: The OC consisted of 99,042 patients of which 28,891 and 30,768 received a balanced transfusion during the first 4 and 24 hours, respectively. The mortality rate plateaued after a TTV of 40.5 units (95% CI, 40-41) in the OC at 4 hours and after a TTV of 52.8 units (95% CI, 52-53) at 24 hours following admission. In the BC, mortality plateaued at a TTV of 39 units (95% CI, 39-39) and 53 units (95% CI, 53-53) at 4- and 24-hours following admission, respectively. CONCLUSION: Transfusion thresholds exist beyond which ongoing transfusion is not associated with any clinically significant change in mortality. These TTVs can be used as markers for resuscitation timeouts in order to assess the plan of care moving forward. LEVEL OF EVIDENCE: Level V, prognostic and epidemiological.

PURPOSE: Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients. METHODS: All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference. RESULTS: 259,399 patients met the study's inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01-1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05-1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11-1.90), p = 0.006], compared to RCRI 0. CONCLUSION: An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population., Funding agency:Örebro University

BACKGROUND: Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner. METHODS: Records were reviewed for all patients admitted between January 2015-December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intra-operative rendezvous ERCP at index admission (one-stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two-stage) at the Irish hospital. Clinical characteristics, post-procedural complications, and inpatient duration were compared between cohorts. RESULTS: Three hundred and fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222(62.2%) underwent a one-stage procedure in Sweden, while 135(37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and pre-operative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein = 136±137 vs. 95±102mg/L,p=0.024), had higher incidence of co-morbidities (age-adjusted Charlson Comorbidity Index ≥3:37.8% vs 20.0%,p=0.003), and overall were less fit for surgery (ASA ≥3: 11.7% vs. 3.7%,p < 0.001). Despite this, a significantly-shorter mean time to definitive treatment, i.e., cholecystectomy (3.1±2.5 vs. 40.3±127 days,p=0.017), without excess morbidity, was seen in the one-stage compared to the two-stage cohort. Patients in the one-stage cohort experienced shorter mean post-procedure length of stay(3.0±4.7 vs 5.0±4.6 days,p < 0.001) and tota

Background: Intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) is common. Yet, its efficacy varies between studies, and the actual effect on the outcome is debated. This study investigates the association of ICP monitoring and clinical outcome in patients with an isolated severe blunt TBI. Patients and Methods: Patients were recruited from the American College of Surgeons-Trauma Quality Improvement Program database during 2014. Inclusion criteria were limited to adult patients (>= 18 years) who had a sustained isolated severe intracranial injury (Abbreviated Injury Scale [AIS] head of >= 3 and Glasgow Coma Scale [GCS] of <= 8) following blunt trauma to the head. Patients with AIS score >0 for any extracranial body area were excluded. Patients' demographics, injury characteristics, interventions, and outcomes were collected for analysis. Patients receiving ICP monitoring were matched in a 1:1 ratio with controls who were not ICP monitored using propensity score matching. Results: A total of 3289 patients met inclusion criteria. Of these, 601 (18.3%) were ICP monitored. After propensity score matching, 557 pairs were available for analysis with a mean age of 44 (standard deviation 18) years and 80.2% of them were male. Median GCS on admission was 4[3,7], and a third of patients required neurosurgical intervention. There were no statistical differences in any variables included in the analysis between the ICP-monitored group and their matched counterparts. ICP-monitored patients required significantly longer intensive care unit and hospital length of stay and had an increased mortality risk with odds ratio of 1.6 (95% confidence interval: 1.1-2.5, P = 0.038). Conclusion: ICP monitoring is associated with increased in-hospital mortality in patients with an isolated severe TBI. Further investigation into which patients may benefit from this intervention is required., DOI https://doi.org/10.4103/JETS.JETS_59_18 fungerar ej som länk

IntroductionOver the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs).MethodsThis multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability.Results1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well.ConclusionThis validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second

BACKGROUND: High-grade traumatic pancreatic injuries are associated with significant morbidity and mortality. Non-resection management is associated with fewer complications in pediatric patients. The present study evaluates outcomes following resection versus non-resection management of severe pancreatic injury caused by penetrating trauma. METHODS: A retrospective study of the Trauma Quality Improvement Program (TQIP) database was performed from 1/2010 to 12/2014. Patients with AAST Organ Injury Scale pancreatic grade III and IV injuries caused by penetrating trauma were included in the study. Demographics, vital signs on admission, Abbreviated Injury Scale per body region, Injury Severity Score, transfusion and therapeutic modality were obtained. Mortality, length of stay (LOS), pseudocyst, pancreatitis, sepsis, thromboembolism, renal failure, ARDS and unplanned ICU admission or re-operation were stratified according to injury grade and treatment modality. Patients were stratified into those who did/did not undergo pancreatic resection. RESULTS: A total of 4,098 patients had a pancreatic injury of which 15.9% (n=653) had a grade III and 6.7% (n=274) a grade IV pancreatic injury. There were no differences in patient demographics or overall injury severity between the resected and non-resected cohorts within each pancreatic injury grade. Forty-two percent of grade III and 38.0% of grade IV injuries underwent pancreatic resection. The total LOS was longer in the resection arm irrespective of pancreatic injury severity. There was no significant difference in morbidity between cohorts. Similarly, mortality was not significantly different between the two management approaches for grade III: 15.1% (95% CI 11.0-19.9) vs. 18.4% (95% CI 14.6-22.6), p=0.32 and grade IV: 24.0% (95% CI: 16.2-33.4) vs. 27.1% (95% CI: 20.5-34.4), p=0.68. CONCLUSION: Resection for treatment of grade III and IV pancreatic injury is not associated with a significant decrease in mortality but is as