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Introduction: The relationship between trauma volumes and patient outcomes continues to be controversial, with limited data available regarding the effect of month-to-month trauma volume variability on clinical results. This study examines the relationship between monthly trauma volume variations and patient mortality at seven Level I Trauma Centers located in the Eastern United States. We hypothesized that higher monthly trauma volumes may be associated with lower corresponding mortality. Methods: Monthly patient volume data were collected from seven Level I Trauma Centers. Additional information retrieved included monthly mortality, demographics, mean monthly injury severity (ISS), and trauma mechanism (blunt versus penetrating). Mortality was utilized as the primary study outcome. Statistical corrections for mean age, gender distribution, ISS, and mechanism of injury were made using analysis of co-variance (ANCOVA). Center-specific, annually-adjusted median monthly volumes (CSAA-MMV) were calculated to standardize patient volume differences across participating institutions. Statistical significance was set at α < 0.05. Results: A total of 604 months of trauma admissions, encompassing 122,197 patients, were analyzed. Controlling for patient age, gender, ISS, and mechanism of injury, aggregate data suggested that monthly trauma volumes < 100 were associated with significantly greater mortality (3.9%) than months with volumes > 400 (mortality 2.9%, p < 0.01). To account for differences in monthly volumes between centers, as well as for temporal bias associated with potential differences over the entire study duration period, data were normalized using CSAA-MMV as a standardized reference point. Monthly volumes ≤ 33% of the CSAA-MMV were associated with adjusted mortality of 5.0% whereas monthly volumes ≥ 134% CSAA-MMV were associated with adjusted mortality of 2.7% (p < 0.01). Conclusions: This hypothesis-generating study suggests that greater monthly trauma volumes appear to be associated with lower mortality. In addition, our data also suggest that across all participating centers mortality may be a function of relative month-to-month volume variation. When normalized to institution-specific, annually-adjusted "median" monthly trauma contacts, we show that months with patient volumes ≤ 33% median may be associated with subtly but not negligibly (1.4–2.3%) higher mortality than months with patient volumes ≥ 134% median. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background The trimodal distribution of traumatic death was first described by Trunkey in 1983, which demonstrated that most deaths occur in the first 24 h. We postulate that since 1983, the time-to-death histogram described has shifted. Methods A retrospective analysis identifying timing of death was conducted on the National Trauma Data Bank (version 7.2) from 2002 to 2006. Early death was defined as death within 24 h of admission. International Classification of Diseases ninth edition codes with greater than 20% early deaths were called “high-risk codes”. Bivariate analyses were conducted to assess the association between demographics, injury factors, and death. Pearson's χ 2 test was used to compare timing of death by region of injury. Multivariate logistic regression was conducted to show the effect of region of injury on death while controlling for demographic factors and injury type. Results The cohort includes 898,982 patients. The study population was predominantly male (66%) and Caucasian (62%). Mean age and injury severity score were 45 ± 20.3 and 11 ± 10, respectively. Overall mortality rate was 5% with 56% dying early. Head/neck, thorax, and abdomen/pelvis injuries were more prevalent in overall deaths (35%, 22%, and 11%, respectively). Thorax and abdomen/pelvis injuries predicted early death (odds ratio 2.03 and 1.39, respectively). Conclusions The prevalence of early death has decreased since 1983, but the majority of deaths still occur within 24 h of injury. Ample opportunity remains to impact mortality in the first 24 h after injury. [ABSTRACT FROM AUTHOR]

Background Venous thromboembolism (VTE) is a major complication of bariatric surgery leading to significant morbidity and mortality. We sought to identify predictive factors that increase the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) using data from the National Surgical Quality Improvement Program (NSQIP). Methods Patients undergoing bariatric procedures from 2005–2012 were identified in the NSQIP database. Pretreatment patient characteristics were examined by laparoscopic and open treatment groups using t tests and chi-square regression. Independent associations between patient characteristics and DVT and PE were examined using logistic regression. Logistic regression was also used to examine whether patients who had postprocedure DVT or PE were more likely than those who did not have these events to have additional morbidity and mortality outcomes. Results 102,869 patients underwent bariatric surgery (96,085 laparoscopic; 6,784 open) from 2005–2012. Preoperative variables associated with increased risk of DVT in laparoscopic bariatric surgery are male gender, higher BMI, congestive heart failure (CHF), and hypertension (HTN). Preoperative variables associated with increased risk of PE in laparoscopic bariatric surgery are male gender, age greater than or equal to 60, higher BMI, African American race, chronic obstructive pulmonary disease (COPD) and CHF. There are no preoperative variables associated with an increased risk of DVT in open bariatric surgery although there is a trend toward significance with CHF. Finally, higher BMI and CHF is associated with an increased risk of PE in open bariatric surgery. Conclusions CHF is a significant risk factor for VTE in bariatric surgery. Surgeons should consider aggressive screening and VTE prophylaxis in patients with CHF and other known risk factors to decrease postoperative morbidity from VTE. [ABSTRACT FROM AUTHOR]

Abstract: Background: The merit of rapid response systems (RRSs) remains controversial. A tailored approach to specific groups may increase the efficacy of these teams. The purpose of this study was to compare differences in triggers for RRS activation, interventions, and outcomes in patients on medical and surgical services. Methods: A retrospective review RRS events was performed. The incidence of out of ICU cardiac arrests and hospital mortality were compared 2 years prior to and following RRS implementation. Call trigger, interventions, and disposition between medical and surgical patients were compared over a 15 month period. Results: Out of ICU cardiac arrest was significantly more prevalent in the medical group both before and after implementation of RRS. The out of ICU cardiac arrest rate decreased 32% in the surgical group (p =0.05) but hospital mortality did not change. Out of ICU cardiac arrest decreased 40% in the medical group (p <0.001) and hospital mortality decreased 25% (p <0.001) following RRS implementation. There were 1082 RRS activations, 286 surgical and 796 medical. Surgical patients were more likely to have received sedation within 24h of evaluation (14% vs. 4%, p <0.001). The majority of patients in both cohorts were discharged alive. Conclusion: Implementation of a RRS had greater impact on reduction of out of ICU cardiac arrest and mortality in medical inpatients. Triggers for activation and interventions were similar between groups; however, surgical patients demonstrated substantial risk for decompensation within the first 24h following operation. More research is needed to evaluate the disproportionate benefit observed between cohorts. [Copyright &y& Elsevier]

The author reflects on the study by H. T. Stelfox and colleagues on the recurrent need of patients to be evaluated by a medical emergency team for rapid response systems (RRS). She says that the study reveals that 10% of recidivism are commonly related to respiratory cause or the lack of intensive care unit (ICU) beds. She adds that recurrence of physiologic deterioration is related to adverse outcomes such as ICU admission, high mortality, and longer ICU stay.

The article discusses the relationship between health insurance and quality of care in the U.S. as of 2014, focusing on a study by Kumar et. al. which examines the effect of insurance status on in-hospital mortality and treatments in patients with septic shock. The author argues that while there is a correlation between lack of insurance and poor medical outcomes, more specific and insightful research on evidence-based interventions regardless of insurance status is warranted.

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 associated with an increase in hospital LOS. [ABSTRACT FROM AUTHOR]

Abstract: Background: Surgical debridement and antibiotics are the mainstays of therapy for patients with necrotizing soft tissue infections (NSTIs), but hyperbaric oxygen therapy (HBO) is often used as an adjunctive measure. Despite this, the efficacy of HBO remains unclear. We hypothesized that HBO would have no effect on mortality or amputation rates. Methods: We performed a retrospective analysis of our institutional experience from 2005 to 2009. Inclusion criteria were age > 18 y and discharge diagnosis of NSTI. We abstracted baseline demographics, physiology, laboratory values, and operative course from the medical record. The primary endpoint was in-hospital mortality; the secondary endpoint was extremity amputation rate. We compared baseline variables using Mann-Whitney, chi-square, and Fisher''s exact test, as appropriate. Significance was set at P < 0.05. Results: We identified 80 cases over the study period. The cohort was 54% male (n = 43) and 53% white (n = 43), and had a mean age of 55 ± 16 y. There were no significant differences in demographics, physiology, or comorbidities between groups. In-hospital mortality was not different between groups (16% in the HBO group versus 19% in the non-HBO group; P = 0.77). In patients with extremity NSTI, the amputation rate did not differ significantly between patients who did not receive HBO and those who did (17% versus 25%; P = 0.46). Conclusions: Hyperbaric oxygen therapy does not appear to decrease in-hospital mortality or amputation rate after in patients with NSTI. There may be a role for HBO in treatment of NSTI; nevertheless, consideration of HBO should never delay operative therapy. Further evidence of efficacy is necessary before HBO can be considered the standard of care in NSTI. [Copyright &y& Elsevier]