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Shift-based models for acute surgical care (ACS), where surgical emergencies are treated by a dedicated team of surgeons working shifts, without a concurrent elective practice, are becoming more common nationwide. We compared the outcomes for appendectomy, one of the most common emergency surgical procedures, between the traditional (TRAD) call and ACS model at the same institution during the same time frame.A retrospective review of patients who underwent laparoscopic appendectomy for acute appendicitis during 2017-2018. ACS and TRAD-patient demographics, clinical presentation, operative details, and outcomes were compared using independent sample t-tests, Wilcoxon rank-sum tests and Fisher's exact or χDemographics, clinical presentation, and complication rates were similar between groups except for a longer duration of symptoms prior to arrival in the TRAD group (Δ = 0.5 d, P = 0.006). Time from admission to operating room (Δ = -1.85 h, P = 0.003), length of hospital stay (Δ = -2.0 d, P 0.001), and total cost (Δ = $ -2477.02, P 0.001) were significantly lower in the ACS group compared to the TRAD group. Furthermore, perforation rates were lower in ACS (8.3% versus 28.6%, P = 0.003). Differences for the outcomes remained significant even after controlling for duration of symptoms prior to arrival (P 0.05).Acute appendicitis managed using the ACS shift-based model seems to be associated with reduced time to operation, hospital stay, and overall cost, with equivalent success rates, compared to TRAD.

We examined the interactive effects of copper (Cu) and overweight (overweight) and obesity on outcomes of burn patients. We posited that higher baseline Cu among burn patients with overweight or obesity will be associated with poor clinical outcomes vs. patients with a normal weight.A retrospective review was conducted on patients with ≥20% total burn surface area (TBSA) with an initial measurement of Cu. Patients were grouped by body mass index (BMI). The interactions between baseline Cu and BMI groups on multiple burn patient outcomes were examined in a series of multiple regression models.One-hundred-and-sixty patients met eligibility (age 43.9 ± 17.5, males 86.3%, normal weight:overweight:obesity = 53:38:69). BMI groups did not differ significantly on demographics, burn severity, or baseline biochemistry. Normal weight patients with higher baseline Cu had shorter ICU stay (ICUS), shorter length of stay (LOS), and had fewer operations (Ps0.05). In contrast, overweight and obese patients with higher baseline Cu had longer ICU stay (p = 0.001 and p = 0.034), LOS (p = 0.005 and p = 0.066), and increased operations (p = 0.001 and p = 0.067).Higher baseline Cu seems associated with adverse outcomes in overweight and obese burn patients. Further research is needed to confirm this association and explore the direction of causality.

Objective/Background Thoracic outlet syndrome (TOS) is most often referred to vascular surgeons. However, there is a lack of understanding of the malpractice cases involving TOS. The goal of this study is to better understand the medicolegal landscape related to the care of TOS. Methods The Westlaw Edge AI-powered proprietary system was retrospectively reviewed for malpractice cases involving TOS. A Boolean search strategy was used to identify target cases under the case category of “Jury Verdicts & Settlements” for all state and federal jurisdictions from 1970 to September 2020. The settled case was described but not included in the statistical analysis. Descriptive statistics were used to report our findings, and when appropriate. The P ≤ .05 decision rule was established a priori as the null hypothesis rejection criterion to determine associations between jury verdicts outcomes and state's tort reform status. Results In this study, 39 cases were identified and met the study's inclusion criteria from the entire Westlaw Edge database. Among plaintiffs who disclosed age and/or gender, median age was 35.0 years with a female majority (67.6%). Cases involving TOS were noted to be steadily decreasing since the mid-1990s. The cases were unevenly spread across 18 states, with the highest number of cases (14, 35.9%) from California and the second highest (4, 10.3%) from Pennsylvania. A similar uneven distribution was seen among U.S. census regions, in which the West had the highest cases (39.5%). The study revealed that more cases were brought to trials in tort reform states (26, 68.4%) than in non-tort reform states (12, 31.6%). A total of 24 of 39 (61.5%) plaintiffs had one specific claim, which resulted in their economic and noneconomic damages. Negligent operation and treatment complication represented an overwhelming majority of claims brought by 38 of 39 plaintiffs (97.4%). Misdiagnosis and lack of informed consent were both brought nine times (23.1%) by the group. Intraoperative nerve injury (20 patients, 51.3%) was the most commonly reported complication. Excluding one case with a settlement of $965,000, 30 of 38 (78.9%) cases went to trials and received defense verdicts. Eight cases (20.5%) were found in favor of plaintiffs with a median payout of $725,581. Conclusions This study highlighted higher than average payouts to plaintiffs and risk factors that may result in malpractice lawsuits for surgeons undertaking TOS treatment. Future studies are needed to further clarify the relationships between tort reform and outcomes of malpractice cases involving TOS.

Length of stay is an important metric in healthcare systems, primarily because it reflects the cost of care provided. In the United States, as in many countries, inpatient hospital stays are significantly more expensive than outpatient care across all healthcare conditions,1 so earlier discharge and transition to outpatient care is crucial to help control the ever-increasing cost of healthcare. In burn patients, length of stay has traditionally been estimated at 1 day per 1% total body surface area of burn. This estimation was first described in a round table discussion in 1986.2 However, since that time there has been significant evolution in the quality of care available to burn patients, in both the operating room and ICU. The use of new harvesting techniques, synthetic dermal substitution, and autologous epidermal skin cell suspension are allowing large, deep burns to be excised and covered in much quicker time frames than historically were possible. Examples include the skin harvesting and wound debridement device for grafting and excision, biodegradable temporizing matrix as a fully synthetic dermal template, and regenerative epidermal suspension concerning cell harvesting. Although these modalities can all be used separately, we believe that using them in conjunction has allowed us to shorten the length of stay in patients with severe partial and full-thickness burns. We present an initial case series of three patients with anticipated hospital lengths of stay of 54.5, 55, and 51 days, who were ready for discharge in 37, 35, and 43 days, respectively.

As the SARS-COV-2 pandemic created the need for social distancing and the implementation of nonessential travel bans, residency and fellowship programs have moved toward a web-based virtual process for applicant interviews. As part of the Society of Asian Academic Surgeons 5th Annual Meeting, an expert panel was convened to provide guidance for prospective applicants who are new to the process. This article provides perspectives from applicants who have successfully navigated the surgical subspecialty fellowship process, as well as program leadership who have held virtual interviews.

Angioembolization (AE) is an adjunct to nonoperative management (NOM) of splenic injuries. We hypothesize that failure of AE is associated with blood transfusion, grade of injury, and technique of AE.We performed a retrospective (2010-2017) multicenter study (nine Level I trauma centers) of adult trauma patients with splenic injuries who underwent splenic AE. Variables included patient physiology, injury grade, transfusion requirement, and embolization technique. The primary outcome was NOM failure requiring splenectomy. Secondary outcomes were mortality, complications, and length of stay.A total of 409 patients met inclusion criteria; only 33 patients (8%) required delayed splenectomy. Patients who failed received more blood in the first 24 h (P = 0.009) and more often received massive transfusion (P = 0.01). There was no difference in failure rates for grade of injury, contrast blush on computed tomography, and branch embolized. After logistic regression, transfusion in the first 24 h was independently associated with failure of NOM (P = 0.02). Patients who failed NOM had more complications (P = 0.002) and spent more days in the intensive care unit (P 0.0001), on the ventilator (P = 0.0001), and in the hospital (P 0.0001). Patients who failed NOM had a higher mortality (15% versus 3%, P = 0.007), and delayed splenectomy was independently associated with mortality (odds ratio, 4.2; 95% confidence interval, 1.2-14.7; P = 0.03).AE for splenic injury leads to effective NOM in 92% of patients. Transfusion in the first 24 h is independently associated with failure of NOM. Patients who required a delayed splenectomy suffered more complications and had higher hospital length of stay. Failure of NOM is independently associated with a fourfold increase in mortality.

Background Hidradenitis suppurativa (HS) is a debilitating skin condition; in severe forms it requires excision and skin grafting for cure. This is commonly performed as a multi-stage procedure; we explored single-stage operation as a more efficient alternative. Methods Retrospective review 2007–2018 evaluating outcomes of patients undergoing single-stage surgery. Results 139 one-stage procedures were performed: 35 excision and primary closure, 104 split-thickness skin grafting (STSG). Success rate was higher for STSG at 75% versus 60% with primary closure. Of failed primary closures, 57% required revision by grafting due to recurrence. Axilla procedures were most successful at 91% compared to 70%, 54%, and 50% for inguinal, gluteal, and perineal areas, respectively. Infection was the most common complication (17%), with 38% requiring readmission. Conclusion Compared to prior literature on multi-stage HS treatment, one-stage operations are a feasible, cost-effective alternative. STSG should remain the procedure of choice, even when primary closure appears feasible.

Introduction Surgical cost is astronomical in the US and instrument standardization is one potential mechanism for cost savings. This study describes a core competency based, multidisciplinary curriculum and evaluates resident attitudes towards operating room equipment standardization. Materials and methods As part of a quality improvement initiative, surgery residents participated in an hour-long mixed curriculum consisting of brief didactics and small group exercises. Participants developed an equipment standardization plan for laparoscopic appendectomy and cholecystectomy. Participants also completed surveys to assess their attitudes towards 11 potential barriers to implementation as “improves, no change, or worsens”. Results Fifteen general surgery residents participated. In general, participants felt that standardization improves or does not change metrics including surgeon autonomy, resident training experience, and patient safety. Conclusion Our pilot curriculum addresses a gap in resident education about surgical cost. Residents generally regard equipment standardization as either improving or not changing hospital metrics.

Laparoscopic cholecystectomy is a common operation; approximately 20 million Americans have gallstones, the most common indication. Surgeons who operate on the biliary tree must be familiar with the presentations and treatment options for acute and chronic biliary pathology. We focus on the difficult "bad" gallbladder. We explore the available evidence as to what to do when a gallbladder is too inflamed, too technically challenging, or a patient is too sick to undergo standard laparoscopic cholecystectomy. We discuss whether or not open cholecystectomy is a relevant tool and what can be done to manage common bile duct stones found unexpectedly intraoperatively.

The aim of this retrospective study was to compare the outcomes of trauma patients directly transported to a level I trauma center (SCENE) versus those who were stabilized at a critical access hospital (CAH) and subsequently transferred.Patients were grouped based on their transfer status, interventions performed at CAH and outcomes. Google Maps was used to calculate the distances from the location of injury (LOI). Each transfer group data was analyzed separately to examine associations of different factors on the outcomes. Outcomes were compared using univariate and multivariate analyses and propensity score matching analysis.There were 262 patients in SCENE and 684 in CAH. Compared to SCENE, CAH had higher rates of blunt injury and a greater distance from LOI, whereas lower ISS score and length of stay (LOS) (p 0.05). The majority of CAH group survived compared to SCENE (p = 0.007). For both groups, baseline factors (e.g., age) were associated with outcomes (p 0.05). Interestingly, longer LOS in the CAH was associated with an increase in survival (p = 0.009), whereas an increased number of CT/MRI performed was associated with increased LOS (p 0.05)., and an increased number of procedures was associated with longer LOS and ICU stay (p 0.05). After matching, the two groups had no significant differences in survival, LOS, or ICU stay (p 0.05).Equivalent overall clinical outcomes were seen in both groups, suggesting that existing trauma system protocols in the West Texas region are functioning well to select appropriate patients for each transfer modality.Retrospective Analysis.

Several options exist for the diagnosis and management of suspected common duct stones. We hypothesized that a protocol-directed approach would shorten length of stay in this patient population.Patients from four participating institutions with a peak bilirubin4 mg/dL underwent surgery as the initial procedure, whereas patients with a bilirubin ≥4 mg/dL underwent endoscopy. The primary endpoint was length of stay. Analysis involved chi square and Wilcoxon-Mann-Whitney test with significance at p 0.05.214 patients were managed under the protocol during six-month study period. 111 patients (52%) required endoscopy and surgery. Length of stay and the number of MRCPs performed pre-operatively significantly decreased following protocol implementation (p 0.05)."Surgery first" approach in patients with bilirubin4 ml/dL resulted in low morbidity and mortality, reduced MRCP, and length of stay.

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p 0.05) as was unplanned re-operation (4.7% vs 14%, p 0.05). Lap reduced LOS (6 vs 8 days, p 0.001). Ileus was more in Lap (42% vs 18 p 0.001) operative time was 14 min higher in Lap(p 0.01) and admission to OR time was 4 h higher in Lap(0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.

Necrotizing soft tissue infections (NSTIs) are associated with high morbidity and mortality and are increasing in incidence. Proper identification of the microbial causes of NSTIs is a crucial step in diagnosis and treatment, but the majority of data collected are culture based, which is biased against fastidious organisms, including obligate anaerobes. The goal of this study was to address this gap in knowledge by characterizing NSTI microbial communities through molecular diagnostics. We performed 16S rRNA sequencing on human NSTI samples and identified five genera most commonly found in NSTIs (Prevotella, Bacteroides, Peptoniphilus, Porphyromonas, and Enterococcus). We found that a >70% contribution of obligate anaerobes to the bacterial population distribution was associated with NSTI mortality, and that NSTI samples, from both survivors and non-survivors, had an increased relative abundance of gram negative bacteria compared to those of abscess patients. Based on our data, we conclude that obligate anaerobes are abundant in NSTIs and a high relative abundance of anaerobes is associated with a worse outcome. We recommend increasing anaerobe antibiotic coverage during the treatment of NSTIs even when anaerobes are not found by traditional clinical microbiology methods, and especially when there is a clinical suspicion for anaerobe involvement.

Choledocholithiasis is present in up to 15% of cholecystectomy patients. Treatment can be surgical, endoscopic, or via interventional radiology. We hypothesized significant heterogeneity between hospitals exists in the approach to suspected common duct stones.A retrospective review of patients that had a preoperative MRCP, endoscopic ultrasound, endoscopic retrograde cholangiopancreatogram (ERCP), or intra-operative cholangiogram was performed. Comparisons were by Wilcoxon-Mann-Whitney tests with significance of p 0.05 for paired variables and p 0.017 for multiple comparisons.Twelve participating institutions identified 1263 patients (409 men and 854 women) with a median age of 49 years (IQR: 31-94). Liver function tests (LFT's) were elevated in 939 patients (75%), median bilirubin level 1.75 mg/dl (IQ: 0.8-3.7 mg/dl) and median common duct size 7 mm (IQR 5-10 mm). The most common initial procedure was cholecystectomy with IOC at seven institutions, endoscopy at four and MRCP at one.Significant variation exists within the surgical community regarding suspected common duct stones. These results underscore the need for a protocol for common duct stones to minimize multiple, redundant interventions.

The COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order.A multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses.Across all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p0.001 and 13.0% vs. 9.9%, p0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618).This multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s).Epidemiological, level IV.

Frequency, microbiology, and outcomes of necrotizing soft tissue infections vary based on locoregional and environmental factors; however, there has been no global survey of these patterns. We performed a systematic review/meta-analysis on published reports of necrotizing soft tissue infections from across the globe.Peer-reviewed empirical studies examining rates of polymicrobial and monomicrobial necrotizing soft tissue infections with microbial isolation and overall mortality rate were extracted along with geographic location using PubMed, Scopus, ProQuest, and Web of Science. Random-effects meta-analyses and sensitivity analyses were performed, adjusting for publication bias. Meta-regression analyses examined moderator effects of risk factors.One hundred and five studies (8,718 total patients) were included. Pooled prevalence of polymicrobial and monomicrobial infections were 53% and 37.9%, respectively. Truncal necrotizing soft tissue infections were commonly polymicrobial (P.001), whereas monomicrobial infections prevailed in extremities (P = .008). Global prevalence of monomicrobial necrotizing soft tissue infections was observed to increase by 1.1% annually (P = .003). Staphylococcus aureus was the most common organism globally and in North America, Asia, the Middle East, and Africa, followed by Streptococcus pyogenes and Escherichia coli. Methicillin-resistant S. aureus accounted for 16% of necrotizing soft tissue infections globally. Overall mortality was 23.1%, observed to decline globally over the last decade (P = .020). No regional differences were noted for mortality.Although polymicrobial infections remain predominant worldwide, the incidence of monomicrobial infections is increasing. The observed decline in necrotizing soft tissue infection-related mortality is encouraging and may reflect advances in management, despite major variations in available healthcare resources globally.

Healthcare disparities are a serious problem that shorten the lives of many Americans, even after accounting for social, cultural, and economic factors and correcting for confounders such as the lack of medical insurance and access to healthcare, black Americans and other minority groups receive worse medical care and experience worse outcomes as a result. Healthcare does not occur in a vacuum; surgeons cannot serve our patients' needs isolated in a bubble and cocooned from larger societal concerns. Although disparities rooted in race likely have the greatest negative effects on our patients' health, plenty of groups exist that have not historically received equal opportunities and acceptance within the surgical world. Despite now accounting for more than one half of all medical graduates, women remain underrepresented in leadership positions, and the gender pay gap has remained significant in all branches of medicine. It will require active, multifaceted, and sustained effort to increase diversity, equity, and inclusion in academic surgery. We have described the steps that can be taken within surgical departments and in national surgical societies to recruit, retain, and foster a diverse surgical workforce and to develop a more inclusive culture within surgery and surgical training.

Introduction A >25% increase in daily insulin dosing is suggestive of possible sepsis in burn patients, however, no conclusive evidence is available regarding the time point at which insulin dosing begins to increase. The purpose of this study is to determine the exact time point at which the insulin requirement increases among non-diabetic burn patients with sepsis. Methods A retrospective chart review in non-diabetic burn patients with ≥20% total body surface area burned (TBSA) during 2010–2018 who received a blood culture for suspected sepsis. Absolute insulin dosing at intervals (0, 24, 48, 72, and 96 h prior to blood culture) were Box–Cox transformed and compared vs.−96 h reference using mixed-effects models accounting for within-patient dependencies. Results Fifty-eight patients (84% males, age 44 ± 17 years, TBSA% 49 ± 17.5) were included. When cube root of daily insulin dosing was regressed on each time point in a mixed-effects model, statistically significant increase in insulin dosing compared to baseline was observed for −48 (p = 0.018), −24 (p = 0.011), and 0 h (p = 0.008). Conclusion Daily insulin dosing increases 48 h prior to development of other clinical signs of sepsis and can be used as a sensitive early marker.

Background In this quality improvement project, we analyzed surgeon focus and attention utilizing a visual tracking device. We hypothesized that surgeons maintained better focus working 12-hour shifts compared to 24-hour calls. Materials and Methods A prospective, quality improvement project was performed on surgery residents, medical students, and attending physicians working at a busy, tertiary referral, safety-net hospital with Level 1 trauma and burn centers. A visual tracking system was used to measure visual attention before and after a 12-hour, in-house shift and a 24-hour, surgical in-house call. A pupil tracker was utilized to measure attention impairment. Individual performance was rated on a scale of 0 to 6: Severely Impaired- 0; Impaired- 1; Low Average- 2; Average- 3; Above Average- 4; High Average- 5; Superior- 6. Data were analyzed for homogeneity. The Wilcoxon Ranked Sum was used to assess for statistically significant differences between focus scores in the same group of individuals before and after shifts and/or calls. The Mann-Whitney U test was used to compare differences in focus between 12 and 24 hour in-house shifts and/or calls. Results A total of 21 surgeons provided a total of 61 visual tracking tests for analysis. Results were found to be nonhomogeneous. The project population was 46% men with a median age of 31 years IQR (28-33). General surgery residents accounted for 48 tests, medical students for 2, and attending surgeons for 11. Average hours of self-reported sleep before the shift/call was 6 (IQR; 6-7). There was almost no overall change in focus in individuals before and after a 12-hour, in-house shift −0.06 (SD 1.9), while after a 24- hour, in-house call, focus decreased by almost 2 full grades −1.8 (SD 1.6) (p = 0.013). There was no statistically significant difference in focus found between 12-hour day shift and 12-hour night shift. Conclusions Twelve-hour shifts appear to preserve focus in surgeons better compared with 24- hour, in-house calls. More research is needed to establish the optimal time of surgeon focus maintenance and shift duration.

Background: Necrotizing soft tissue infections (NSTIs) are a group of rapidly progressive infections of the skin and its underlying tissue. These infections result in substantial morbidity and mort...

This commentary discusses ethical implications of the common practice of treating children's and adults' burn pain differently. Physicians have obligations to ensure that (1) their own discomfort with children's pain doesn't lead them to make pain management decisions that could place a patient at greater risk and (2) to engage in thoughtful, individualized pain management strategies. Long-term consequences of overzealous pain medication administration, for example, could include delayed recovery and integration or opioid dependence. The need to create individualized approaches to pain management, based on published guidelines, is discussed along with uses of nonpharmacological treatment for both adults and children.

Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.

Introduction The literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population. Methods From 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI – Surgical Site Infection, DSI – Deep Space Infection, and OSI – Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality. Results Out of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls. Conclusions Our analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy.

Controversy exists regarding how quickly an adult with appendicitis requires surgery to prevent perforation, and recent literature on antibiotic use as definitive treatment has complicated this question further. Since perforation is associated with worse outcomes, particularly in the elderly, efforts to prevent this complication are warranted. We studied risk factors for in-hospital perforation in patients diagnosed by admission CT with non-perforated acute appendicitis.We evaluated baseline demographics, symptom duration, and time from admission to antibiotics and surgery. Outcome measure was perforation diagnosed intra-operatively by attending surgeon.Of 700 patients, 84 (12%) sustained in-hospital perforation; time from admission to operation or antibiotics were not associated. Duration of symptoms24 h (aOR = 2.23, 95% CI = 1.33-3.72, p 0.001) increased perforation risk. Patient age over 46 years (aOR = 4.54, 95% CI = 2.04-10.06, p 0.001) was also associated with higher risk that increased with increasing age.Time to operation and antibiotic timing were not associated with in-hospital perforation in a general adult population. However, these findings suggest a possible benefit to expedient surgery in older patients.

Surgical debridement and broad-spectrum empiric antibiotics are first-line therapy for necrotizing soft tissue infections (NSTI). The objective of this multi-center retrospective review was to evaluate antimicrobial agent initiation and duration and compare outcomes in the treatment of patients with NSTI.This review included adults with NSTI, as indicated by International Classification of Diseases, 9th Edition, Clinical Modification codes 728.86, 608.33, or 040.0, who were admitted to three academic institutions between 1/1/09 and 5/15/14. Demographics, antibiotic practices, operative management, and clinical outcomes were compared.A total of 341 patients were identified at the three centers. Subjects were comparable in age (median 53 years, p = 0.14), gender (67% male, p = 0.57) and body mass index (median 31.9 (p = 0.31) between sites. No significant difference was found in time from admission to start of empiric antibiotic therapy between the three centers (median 1 d for each, p = 0.70), but duration of antibiotic therapy was significantly different (Site A = 16 d, Site B = 12 d, Site C = 9 d, medians, p 0.001). Although total number of operations differed between sites (median of two at Sites A and B, three at Site C, p = 0.001), sites consistently operated on the day of patient arrival to their facility, and the number of debridements did not differ (median of two for all sites, p = 0.10). Mortality rate (Site A = 22%, Site B = 18%, and Site C = 9%, p = 0.02) and length of stay for survivors (Site A = 29 d, Site B = 16 d, Site C = 19 d, medians, p = 0.001) was significantly different among centers.Variation in antibiotic duration between centers with expertise in the care of NSTI illustrates how little is known about best care practices for patients with NSTI. Future studies should emphasize development of evidence-based practices for NSTI management to further improve the outcomes of this complex group of patients.

Since 1981, the number of US burn centers has decreased by 29%, resulting in more long distance referrals to remaining facilities. Air transport is often the only feasible method for remote patients to reach few remaining burn centers. A significant proportion of flown-in patients have minor burns and are discharged within 24 hours, representing potential over-utilization of resources with increased cost to the healthcare system for no perceptible benefit. We explored factors associated with air transport of burns and opportunities for system improvement. Retrospective review of burn patients transferred by air to regional burn center between January 2003 and June 2013. Demographic, injury and clinical outcome data were acquired from the institutional Burn Registry. Minor burns constituted 17.7% of all flown admits (236/1331). Children were more likely to be included in this cohort at 32% vs 21.6% of adults (P = .0004). The overtriaged cohort had significantly lower % total BSA than accurately triaged cohort (3.3% vs 15%; P = .0001). Subjects with electrical burn injury were twice as likely to be overtriaged than accurately triaged (10.6% vs 5%; P = .002). The average % total BSA in the overtriaged group was 3.3%; the face was most common area burned (47.7%). The average estimate of charges for transfer was between $25,000 and 30,000/patient. The incidence of overtriage among flown-in burn patients, approximately 20%, represents substantial unnecessary healthcare expenditure. Improved burn care education, incentives to increase use of telemedicine, and modification of American Burn Association guidelines to include consultation with a burn center rather than automatic transfer are needed to reduce this cost to the healthcare system.

The objective of this article is to explore the impact of socioeconomic status on outcome metrics in post-burn injury patients. Retrospective review of patients with TBSA15% between 2005 and 2012. Demographics and clinical course were recorded. Socioeconomics were approximated using census data of percent below poverty level at patient zip code, which was also used for calculating distance to regional burn center. Statistical analysis was performed using Statistical Analysis Software. Odds ratios and 95% confidence intervals were calculated followed by regression models for factors associated with graft loss and readmission. Two hundred and fifty subjects survived to discharge: 33% were of upper socioeconomic status, 32% were of middle status, and 35% were of lower status. Fourteen percentage of patients lived99 miles from the burn center, 60% 100 to 249 miles away, and 26%240 miles away. Eighty readmissions occurred among 39 patients; 43% were unplanned. Each percent increase in TBSA was associated with a 5% increase in likelihood of being readmitted. Thirty six percentage of readmission patients were covered under worker's compensation. Patients with worker's compensation were four times more likely to be readmitted than private insurance. Only worker's compensation had a majority of unplanned readmissions (58%). Graft loss occurred in 12% of patients. Those in the low socioeconomic group had five times the odds of having graft loss than those in the high socioeconomics. There was no correlation between graft loss and insurance status or distance. Findings indicate strong and statistically significant correlations between type of insurance and likelihood of readmission and between graft loss and poverty.

Smoke inhalation and carbon monoxide poisoning are a significant cause of mortality and neurologic morbidity. We present the unusual case of complete neurologic survival after prolonged hypoxia, severe acidosis, out of hospital cardiac arrest, and exposure to high levels of carbon monoxide poisoning in a patient with sickle cell disease. The hypothesis that there might be a potential protective effect from the type of hemoglobin seen in patients with sickle cell disease in carbon monoxide poisoning is discussed.

Objective: Necrotising soft tissue infections (NSTIs) progress rapidly and mortality remains high, ranging from 10% to 30%, representing a significant challenge for health professionals. Early accurate diagnosis is crucial because timely and aggressive surgical intervention remains the number one indicator for a better clinical outcome. Understanding the microbial background of NSTIs would aid early diagnosis. Presentation: We present a case of NSTI, in a seemingly healthy adult male, originating from a tooth abscess. The NSTI progressed rapidly, and eventually covered the patient's chest and abdominal skin and underlying soft tissue. Results: Traditional blood and tissue culture only found Group C Streptococcus where 16S sequencing detected abundant Prevotella spp., a more likely causal organisms of the NSTI. The use of antibiotics with the approriate anaerobe coverage, in combination with timely surgical intervention, contributed to the ultimate successful clinical outcome. Complete wound healing and successful graft was achieved within one month of diagnosis of the microbes present. Conclusion: While surgical intervention remains the most important consideration in treatment of NSTI, correct identifcation of the microbial flora could also contribute to successful treatment.

Introduction Venous thromboembolism (VTE) remains one of the principal causes of morbidity and death in trauma patients that survive the first 24 h. Recent literature on VTE prevention focuses on choice of chemoprophylaxis, specifically unfractionated heparin (UFH) versus low molecular weight heparin (LMWH). This singular focus on a multifactorial process may be inadequate to fully understand the optimal approach to VTE prevention. We hypothesized that variations in care between trauma centers could be used to identify key components of VTE prevention associated with better outcomes. Methods A 50 question survey of VTE management for years 2014–2016 was sent to 15 trauma centers. The survey included: demographics of the trauma centers, type and timing of chemoprophylaxis, ambulation expectations, and complementary services (geriatric trauma service (GTS), mobility teams, physical and occupational therapy (PT/OT)). Each center submitted their American College of Surgeons Trauma Quality Improvement Program (TQIP) Benchmark Report for Spring 2017. TQIP data included: mortality, observed rates of deep vein thrombosis (DVT) and pulmonary embolus (PE), and time to VTE prophylaxis. The survey and TQIP reports were blinded for analysis; descriptive statistics were utilized. The top DVT & PE TQIP performers were used to identify potential aspects of better care on the survey responses. The institutions’ DVT and PE rates were then compared for these responses using Wilcoxon-Rank-Sum test. Results Fifteen trauma centers (13 Level-1, 2 Level-2) completed the survey; the centers admitted 1050–7200 trauma patients per year (median 3000). The majority of centers were University-affiliated (11 of 15) with general surgery residencies (14 of 15), Acute Care Surgery or Surgical Critical Care Fellowships, (9 of 15) and critical care boarded-surgeons only on-call (9 of 15). Few have geriatric trauma services (3 of 15) or mobility teams (1 of 15). Half the trauma centers have dedicated PT/OT teams for trauma or weekend coverage. With a total of 20,878 TQIP patients analyzed, the average observed DVT and PE rates were 1.27% (range 0.1–5.2%) and 0.68% (range 0–1.6%), respectively. Weekly lower extremity surveillance duplex (2 of 15) increased DVT detection (4.15% vs 0.80%, p = 0.034) but did not decrease PE rates (1.05% vs 0.62%, p = 0.229). Great variance was seen in choice, dosing and timing of chemoprophylaxis: UFH,4 LMWH daily,1 LMWH twice-daily,5 LMWH weight-based dosing,4 and LMWH anti-Xa dosing.1 The top 3 performers for DVT and PE all used different types of chemoprophylaxis. These top performers had a prominent culture of mobility: dedicated PT/OT teams for trauma or weekends and an expectation to ambulate 3-times per day. Weekend PT/OT teams were associated with lower DVT rates (median 0.40%, range 0.10–1.10% vs 1.30%, 0.60–5.20%, p = 0.018), and ambulation 3-times per day was associated with lower PE rates (median 0.20%, range 0.00–0.20% vs 0.80%, 0.40–1.60%, p Conclusions Considerable variation in VTE chemoprophylaxis exists among trauma centers. “Best practices” in this area requires further investigation. An expectation of mobility and investment in mobility resources may serve to decrease VTE rates in trauma patients compared to a singular focus on type of chemoprophylaxis administered.

The standard treatment of necrotizing soft tissue infection (NSTI) includes extensive surgical debridement. Care of these debridements is challenging because of the size of the wound and associated pain. A potential solution is to leave the wounds open-to-air in the period after the initial debridement, allowing for regular inspection at bedside while reducing pain associated with frequent dressing changes. We evaluated the feasibility of this approach from a pain control standpoint.An audit of wound care modalities used on adult patients with NSTI admitted to a regional burn center between January 2009 and May 2014 was performed. Patients with at least one operation were included. Those opting for palliative care were excluded. Wound care was divided into four categories: open-to-air (OTA), negative-pressure wound therapy (NPWT), packing, and ointment. Wound care, pain score, pain medication use, and number of operations were collected for the first seven days after initial debridement. Pain management was assessed by pain scores. Analgesic use was measured and compared using conversion to morphine milligram equivalents (MME).Ninety-six patients were included; 67% were men with average age of 50 years, resulting in a total of 672 days of wound care evaluated: 69 days of OTA, 127 days of NPWT, 200 days of packing, and 126 days of ointment (150 days were undocumented). Average daily pain score from all wound care modalities was 2.00. Negative pressure wound therapy had the highest reported daily pain score (2.18, p = 0.034), whereas OTA had the lowest pain score (1.63, p 0.05). Mortality was lower in the OTA cohort but was not statistically significant; there were no other differences in long-term outcome.Leaving wounds OTA is a safe and viable option in the immediate post-debridement period of NSTI to reduce pain, while permitting frequent re-evaluation for quick recognition of disease progression and repeat operative debridement if necessary.

Burn injury rates appear to be influenced by socioeconomic status (SES) and gender globally, but the impact of poverty and gender on burn injury has not been studied in a developed country. This study was a retrospective chart review conducted at a regional burn center in the Southwest US that included 340 patients with TBSA burns >15%. SES was determined using zip code and US census data. The distribution of mechanism of injury was significantly different by gender (χ2(6) = 36.14, p < 0001), but not significantly different by SES (χ2(12) = 19.68, p = 0.073). Burn rates in women was found to have a significant and linear increase (χ2 = 13.8513, p = 0.001) with increasing poverty. Women had higher frequencies of being burned at home, and men had higher frequencies of being burned at work. While poverty did not appear to increase the risk of burn injury overall in a mixed population, it was associated with a significant increase in the risk of burn injury in women. Thus, strategies for decreasing risk factors should be targeted toward low SES females and the working male.

Removal is the standard treatment for mesh infection following prosthetic hernia repair. However, certain types of mesh may be less amenable to removal even in the setting of active infection; we present four such cases, all involving the same composite mesh. Four high-risk patients underwent Parietex mesh implantation for large ventral wall hernias and developed subsequent Staphylococcus infections with attempted explantation of infected mesh and wound care. There was inability to completely explant mesh in all four cases, leading to chronic purulent wounds and long-term complications. While mesh infection is a recognized complication of prosthetic hernia repair, many synthetic meshes form a slimy biofilm and thus can be removed relatively easily. However, the structural qualities of certain types of mesh create ingrowth into tissues even in the setting of infection, resulting in inability to explant with subsequent long-term chronic wound complications.

Objective:To determine noise intensity during middle-ear aspiration in order to evaluate whether levels can be potentially harmful.Methods:In this prospective, observational study, middle-ear effusion was aspirated following myringotomy using a suction instrument with a probe tube microphone. Sound pressure levels and duration were measured, and frequency domain analysis was performed.Results:Forty-four ears were analysed, consisting of 20 with mucoid effusion, 11 with serous effusion and 13 with no effusion. Maximum peak sound intensity ranged from 84 to 157 dB. Half of the ears (50 per cent) were exposed to greater than 140 dB; of these, 82 per cent were exposed for longer than 0.2 ms (range, 0.05–14 ms). There was no significant difference in sound pressure level between ears with mucoid and serous effusion; however, ears with mucoid effusion required longer suction times (p p Conclusion:Middle-ear aspiration during myringotomy caused noise levels within a potentially harmful range.

Background Guidelines are in place directing the clearance of the cervical spine in patients who are awake, alert, and oriented, but a gold standard has not been recognized for patients who are obtunded. Our study is designed to determine if magnetic resonance imaging (MRI) detects clinically significant injuries not seen on computed tomographic (CT) scans. Methods The trauma registry was used to identify and retrospectively review medical records of blunt trauma patients from January 1, 2005, to March 30, 2012. Only obtunded patients with a CT scan and MRI of the cervical spine were included. Results The study cohort consisted of 277 patients. In 13 (5%) patients, MRI detected clinically significant cervical spine injuries that were missed by CT scans, and in 7 (3%) these injuries required intervention. The number needed to screen with MRI to prevent 1 missed injury was 21. Conclusions The findings suggest that the routine use of MRI in clearing the cervical spine in the obtunded blunt trauma patient.

As monitoring requirements for healthcare-acquired infection increase, an efficient and accurate method for surveillance has been sought. The authors evaluated the accuracy of electronic surveillance in multiple intensive care unit settings. Data from 500 intensive care unit patients were reviewed to determine the presence of central line-associated blood stream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). An electronic surveillance report was obtained to determine whether patients had a blood-line nosocomial infection marker or a urine nosocomial infection marker. Manual review was based on Centers for Disease Control and Prevention criteria. An infection preventionist then reviewed all discrepant cases and made a final determination, which was used as the gold standard. Sensitivity, specificity, false-positive rate, and false-negative rate were then calculated for electronic surveillance. In the burn population the sensitivity of electronic surveillance for CAUTI was 66.66%, specificity 96.5%, false-positive rate 3.44%, false-negative rate 33%; and for CLABSI the sensitivity was 100%, specificity 95%, false-positive rate 4.96%, false-negative rate 0%. In the nonburn population the sensitivity for CAUTI was 50%, specificity 97.9%, false-positive rate 2%, and false-negative rate 30%; and for CLABSI sensitivity was 60%, specificity 98.8%, false-positive rate 1%, and false-negative rate 60%. Burn centers may experience a higher false-positive rate for electronic surveillance of CLABSI and CAUTI than other critical care units.

Necrotizing soft tissue infections (NSTIs) are the most severe and rapidly progressing class of skin and soft tissue infections (SSTIs). They are a surgical emergency and are associated with high mortality and morbidity. While NSTIs remain relatively rare, their incidence is steadily rising. Earlier diagnosis and more focused antibiotic treatments can potentially improve patient outcome, but both of these solutions require a more accurate understanding of the microbial component of these infections. While molecular detection methods, namely 16S sequencing, have not been traditionally used to identify the causative microorganisms in NSTIs, they are becoming more commonplace for other types of SSTIs, especially for chronic wound infections. In chronic wound infections, 16S sequencing has revealed a higher than previously detected prevalence of obligate anaerobes. Therefore, it is possible that 16S sequencing may also detect a higher than expected proportion of obligate anaerobes in NSTIs. In this review, we discuss the current state of knowledge concerning the diagnosis and treatment of NSTIs and present reasons why the role of anaerobes may be significantly underestimated.

• Incidence and prevalence of burnout among US physicians and surgeons, with discussion of variation between specialties.

Soft tissue infections have historically been diagnosed on the basis of clinical signs and symptoms. A trend toward the increased use of computed tomographic (CT) imaging in their evaluation has been noted.A retrospective review was performed of soft tissue infection admissions in 2003 and 2004 and in 2009 and 2010. Intracavitary abscesses (eg, intra-abdominal, pelvic) that would not be evident on physical examination were excluded. Demographic and outcome variables, number of CT scans by body region, and total effective radiation dose were recorded. Radiation exposure was stratified into low, moderate, high, and very high categories.There was a significant increase in the number of patients receiving ≥1 CT scan for initial diagnosis, from 36.7% in the early cohort to 50% in the later cohort (P.001). The mean cumulative effective dose increased from 5.46 to 7.82 mSv (P = .007). Greater proportions of patients fell into the moderate (32.9% vs 24.5%) and high (6.8% vs 10.6%) radiation exposure categories.CT scans are increasingly used in the evaluation of soft tissue infections, with resultant increase in radiation exposure.

Despite the development of several prediction rules to guide head CT imaging, determining whom to screen for head trauma in the geriatric population after a ground level fall remains controversial. The purpose of this study was to assess the impact of head CT on the management of older adult patients who present with a normal GCS after a ground level fall, and to identify factors that could predict the need for neurosurgical intervention.A retrospective study was conducted on hemodynamically stable patients55 years of age with GCS of 15, who presented to a level 1 trauma center after a ground level fall. Radiological reads of head CT scans were reviewed for new findings and clinical documentation was analyzed for evidence of a change in management. Univariate analysis of key demographic and clinical factors was performed to probe for statistically significant differences between patients receiving medical management versus surgical management.Of 437 patients receiving head CTs, 146 (33.4%) had a positive finding. 95 (21.7%) patients had a change in management; 76 (17.4%) were medication changes and 19 (4.3%) required neurosurgical intervention. Age 85 years and older, and having a neurologic deficit on initial physical examination were found to be significantly associated with the need for neurosurgery.The results of this study confirm that head CT findings often alter clinical management of elderly patients presenting with a GCS of 15 after ground level falls, and should be a part of standard evaluation.