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A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used. However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported. The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an 'optimum' itself has important implications for ethics and the law. [ABSTRACT FROM AUTHOR]

Introduction: Multiple studies have demonstrated a linear association between advancing age and mortality after injury. An inflection point, or an age at which outcomes begin to differ, has not been previously described. We hypothesized that the relationship between age and mortality after injury is non-linear and an inflection point exists. Methods: We performed a retrospective cohort analysis at our urban level I center from 2007 through 2009. All patients aged 65 years and older with the admission diagnosis of injury were included. Non-parametric logistic regression was used to identify the functional form between mortality and age. Multivariate logistic regression was utilized to explore the association between age and mortality. Age 65 years was used as the reference. Significance was defined as p < 0.05. Results: A total of 1,107 patients were included in the analysis. One-third required intensive care unit (ICU) admission and 48 % had traumatic brain injury. 229 patients (20.6 %) were 84 years of age or older. The overall mortality was 7.2 %. Our model indicates that mortality is a quadratic function of age. After controlling for confounders, age is associated with mortality with a regression coefficient of 1.08 for the linear term ( p = 0.02) and a regression coefficient of −0.006 for the quadratic term ( p = 0.03). The model identified 84.4 years of age as the inflection point at which mortality rates begin to decline. Conclusions: The risk of death after injury varies linearly with age until 84 years. After 84 years of age, the mortality rates decline. These findings may reflect the varying severity of comorbidities and differences in baseline functional status in elderly trauma patients. Specifically, a proportion of our injured patient population less than 84 years old may be more frail, contributing to increased mortality after trauma, whereas a larger proportion of our injured patients over 84 years old, by virtue of reaching this advanced age, may, in fact, be less frail, contributing to less risk of death. [ABSTRACT FROM AUTHOR]

Background: Frailty syndrome is an established predictor of adverse outcomes after surgical procedures. Our study aimed to compare the simplified National Surgical Quality Improvement Program 5-factor-modified frailty index (mFI-5) to its prior 11-factor-modified frailty index (mFI-11) with respect to the predictive ability for mortality, postoperative complications, and unplanned 30-d readmission in patients undergoing lower limb amputation., Methods: The National Surgical Quality Improvement Program (2005-2012) databank was queried for all geriatric patients (>65 y) who underwent above-knee and below-knee amputations. We calculated each mFI by dividing the number of factors present for a patient by the total number of available factors. To assess the correlation between the mFI-5 and mFI-11, we used Spearman's rho rank coefficient. We then compared the two indices for each outcome (30-d complication, 30-d mortality, and 30-d readmission) and C-Statistic using predictive models., Results: A total of 8681 patients were included with mean age of 76 ± 9 y, complication rate 35.8%, mortality rate 10.2%, and readmission rate 15.9%. There was no difference in type of amputation in frail and nonfrail. Correlation between the mFI-5 and mFI-11 was above 0.9 for all outcome measures. Both mFI-5 and mFI-11 indexes had strong predictive ability for mortality, postoperative complications, and 30-d readmissions., Conclusions: In patients undergoing major lower limb amputation, we found mFI-5 and the mFI-11 were equally effective in predicting postoperative outcomes. Frailty remained a strong predictor of postoperative complications, mortality, and 30-d readmission., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Frailty syndrome confers a greater risk of morbidity and mortality after operative interventions. The aim of the present study was to assess the effect of frailty on the outcomes after carotid interventions, including both carotid endarterectomy (CEA) and carotid artery stenting (CAS)., Methods: We performed an 8-year (2005-2012) retrospective analysis of the National Surgery Quality and Improvement Program database, including patients who had undergone CEA or CAS for carotid artery stenosis. A modified frailty index score was calculated. Frail status was defined as a modified frailty index score of ≥0.27. The outcome measures were inpatient complications, mortality, failure to rescue (FTR), hospital length of stay, and 30-day readmissions. Multivariable regression analysis was performed to study the association between frailty and the perioperative outcomes., Results: The data from 37,875 patients were included. Of the 37,875 patients, 95.7% had undergone CEA, and 27.3% of the patients were frail (27% of the CEA and 26% of the CAS groups had qualified as frail). Overall, 11.7% of the patients had experienced complications, 2.2% had died, and 6.7% had been readmitted after discharge. On regression analysis, after controlling for age, gender, albumin level, type of surgery, and American Society of Anesthesiologists class, frail status was an independent predictor of complications (23.5% vs 7.2%; P < .001), mortality (5.2% vs 1.1%; P = .02), FTR (12.1% vs 4.7%; P = .02), and 30-day readmissions (14.9% vs 3.7%; P = .03). On subanalysis of the patients who had undergone CAS, no association was found between frail status and the occurrence of complications (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.8-3.2), mortality (OR, 1.2; 95% CI, 0.6-2.7), FTR (OR, 0.9; 95% CI, 0.4-2.3), and 30-day readmission rate (OR, 1.1; 95% CI, 0.5-3.1)., Conclusions: Frailty syndrome was associated with morbidity and mortality among patients undergoing surgical interventions for carotid stenosis. In the present study, frailty was associated with significant mortality and morbidity for those who had undergone CEA but not for those who had undergone CAS. However, the present study was not designed to determine the optimal treatment of frail patients. Incorporating frailty status into the treatment algorithm (CEA vs CAS) might provide a more accurate risk assessment and improve patient outcomes., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical site infection (SSI) is an established quality indicator and predictor for adverse patient outcomes. Multiple strategies have been established to reduce SSI; however, optimum protocol remains unclear. The aim of the study was to assess the impact of established protocol on SSI after colon surgery., Methods: We established a colon SSI bundle in 2017, which includes a chlorhexidine prescrub followed by chloraPrep, betadine wound wash, antibiotic infused irrigation, use of closure tray, and incision coverage with silver impregnated dressing. Retrospective analysis of a 2-y (2016-2017) prospectively collected before and after analysis of all patients undergoing elective colon surgery was performed. Patients were divided into two groups: preprotocol (PP: year 2016) and postprotocol (PoP: year 2017). Patients in the two groups were matched using propensity score matching for age, gender, comorbidities, Anesthesiology Severity Score, indication of procedure, and procedure type. Outcome measures were SSI, hospital length of stay, and readmission rate., Results: A total of 328 patients were analyzed, and after propensity matching, 94 patients (PP:47 and PoP:47) were included. The mean age was 63.7 ± 16.4 y, 43.6% male, and 44.6% of procedures were performed laparoscopically. There was no difference in demographics, comorbidities, and procedure details between two groups. PoP patients had significantly lower superficial (odds ratio: 0.91 [0.74-0.98]; P = 0.045) and deep SSI (odds ratio:0.97 [0.65-0.99]; P = 0.048) than PP patients. PoP patient had shorter length of stay (P = 0.049) and trend toward lower readmission rate (P = 0.098) compared with PP patients and an 85% reduction in the Centers for Medicare and Medicaid Services standardized infection rate., Conclusions: Protocol-driven patient care improves patient outcomes. SSI bundle reduced SSI in patient undergoing colon surgery. Establishing national SSI bundles will help standardize care and help optimize patient outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The influence of hospital-related factors on outcomes following colorectal surgery is not well-established. The aim of our study was to evaluate the relationship between hospital factors on outcomes in surgically managed colorectal cancer patients., Methods: We performed a 2-year (2014-2015) analysis of the NIS database. Adult (> 18 years) patients who underwent open or laparoscopic colorectal resection were identified using ICD-9 codes. Patients were stratified based on hospital: volume (low vs. high), teaching status, and location (urban vs. rural). Outcome measures were complications and mortality. Multivariate logistic regression was performed., Results: A total of 153,453 patients with CRC were identified of which 35.3% underwent surgical management. Mean age was 69 ± 13 years, 51.6% were female, and 67% were white. Twenty-seven percent of the patients were managed at a high-volume center, 48% at intermediate-volume center while 25% at a low-volume center. Complications and mortality rates were lower in patients who were managed at high-volume centers and urban hospitals, while no difference was noticed based on teaching status. On regression analysis, patients managed at high-volume centers (OR 0.76 [0.56-0.89]) and urban hospitals (OR 0.83 [0.64-0.91]) have lower odds of complications; similarly, high-volume centers (OR 0.79 [0.65-0.90]) and urban facility (OR 0.87 [0.70-0.92]) were associated with lower odds of mortality. However, there was no association between teaching status and outcomes., Conclusion: Hospital factors significantly influence outcomes in patients with CRC managed surgically. High-volume centers and urban facilities have relatively better outcomes. Regionalization of care along with the appropriate availability of resources may improve outcomes in patients with CRC., Level of Evidence: Level III, Retrospective Observational Study.

Background: Failure to rescue (FTR) is an important measure of quality of care. The aim of this study was to assess FTR in patients with colon cancer (CC) who underwent surgical resection. We hypothesized that patient managed in urban centers had lower FTR., Methods: We performed a 1-y (2011) retrospective analysis of the National Inpatient Sample database and identified all patients with CC who underwent surgical management. Patients were stratified based on the location of treatment: urban versus rural. Outcome measure was FTR, which was defined as death after major complications. Regression analysis was performed to evaluate the independent predictors of FTR., Results: A total of 49,789 patients with CC who underwent surgery were analyzed. The mean age was 71 ± 20.2 y and 59% were males. About 21.5% patients developed in-hospital complications. The overall rates of complications, mortality, and FTR were 21.5%, 3.0%, and 33.8% respectively. Patient managed in rural centers had higher FTR compared with urban centers (39.5% versus 30.1%, P = 0.01). On regression analysis after controlling for age, gender, type of procedure, Charlson Comorbidity Index, and insurance status, management in rural center was independently associated with FTR (odds ratio: 1.9 [1.4-3.7]). On subanalysis of urban centers, management in teaching urban hospital was independently associated with higher FTR (odds ratio: 1.4 [1.2-3.8])., Conclusions: Disparities exist among centers managing patients with CC undergoing surgical intervention. Rural centers have higher FTR compared with similar cohort of patients managed in urban centers. Teaching urban hospital performed worse than nonteaching urban centers. Understanding the reason for these differences may help standardize care across centers and help improve patient outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Importance: Domestic violence is an extremely underreported crime and a growing social problem in the United States. However, the true burden of the problem remains unknown., Objective: To assess the reported prevalence of domestic violence among trauma patients., Design, Setting, and Participants: A 6-year (2007-2012) retrospective analysis of the prospectively maintained National Trauma Data Bank. Trauma patients who experienced domestic violence and who presented to trauma centers participating in the National Trauma Data Bank were identified using International Classification of Diseases, Ninth Revision diagnosis codes (995.80-995.85, 995.50, 995.52-995.55, and 995.59) and E codes (E967.0-E967.9). Patients were stratified by age into 3 groups: children (≤18 years), adults (19-54 years), and elderly patients (≥55 years). Trend analysis was performed on April 10, 2014, to assess the reported prevalence of domestic violence over the years., Participants: Trauma patients presenting to trauma centers participating in the National Trauma Data Bank., Main Outcomes and Measures: To assess the reported prevalence of domestic violence among trauma patients., Results: A total of 16 575 trauma patients who experienced domestic violence were included. Of these trauma patients, 10 224 (61.7%) were children, 5503 (33.2%) were adults, and 848 (5.1%) were elderly patients. The mean (SD) age was 15.9 (20.6), the mean (SD) Injury Severity Score was 10.9 (9.6), and 8397 (50.7%) were male patients. Head injuries (46.8% of patients) and extremity fractures (31.2% of patients) were the most common injuries. A total of 12 515 patients (75.1%) were discharged home, and the overall mortality rate was 5.9% (n = 980). The overall reported prevalence of domestic violence among trauma patients was 5.7 cases per 1000 trauma center discharges. The prevalence of domestic violence increased among children (14.0 cases per 1000 trauma center discharges in 2007 to 18.5 case per 1000 trauma center discharges in 2012; P = .001) and adults (3.2 cases per 1000 discharges in 2007 to 4.5 cases per 1000 discharges in 2012; P = .001) over the 6-year period and remained unchanged for elderly patients (0.8 cases per 1000 discharges in 2007 to 0.96 cases per 1000 discharges in 2012; P = .09). On subanalysis of adults and elderly patients, the prevalence of domestic violence increased among both female (4.6 cases per 1000 discharges in 2007 to 5.3 cases per 1000 discharges in 2012; P = .001) and male patients (1.5 cases per 1000 discharges in 2007 to 2.8 cases per 1000 discharges in 2012; P = .001)., Conclusions and Relevance: Domestic violence is prevalent among trauma patients. Over the years, the reported prevalence of domestic violence has been increasing among children and adults, and continues to remain high among female trauma patients. A robust mandatory screening for evaluating domestic violence among trauma patients, along with a focused national intervention, is warranted.

Background: Organ donation after cardiac death (DCD) is not optimal but still remains a valuable source of organ donation in trauma donors. The aim of this study was to assess national trends in DCD from trauma patients., Methods: A 12-year (2002 to 2013) retrospective analysis of the United Network for Organ Sharing database was performed. Outcome measures were the following: proportion of DCD donors over the years and number and type of solid organs donated., Results: DCD resulted in procurement of 16,248 solid organs from 8,724 donors. The number of organs donated per donor remained unchanged over the study period (P = .1). DCD increased significantly from 3.1% in 2002 to 14.6% in 2013 (P = .001). There was a significant increase in the proportion of kidney (2002: 3.4% vs 2013: 16.3%, P = .001) and liver (2002: 1.6% vs 2013: 5%, P = .041) donation among DCD donors over the study period., Conclusions: DCD from trauma donors provides a significant source of solid organs. The proportion of DCD donors increased significantly over the last 12 years., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI., Methods: Version 7.2 of the National Trauma Data Bank (2007-2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications., Results: A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1-2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1-2.8, P = 0.009) in patients with isolated severe TBI., Conclusions: ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To determine the impact of the increasing aging population on trauma mortality relative to mortality from cancer and heart disease in the United States., Background: The population in the United States continues to increase as medical advancements allow people to live longer. The resulting changes in the leading causes of death have not yet been recognized., Methods: Data were obtained (2000-2010) from the Web-based Injury Statistics Query and Reporting System database of the Centers for Disease Control and Prevention. We defined trauma deaths as unintentional injuries, suicides, and homicides., Results: From 2000 to 2010, the US population increased by 9.7% and the number of trauma deaths increased by 22.8%. Trauma deaths and death rates deceased in individuals younger than 25 years but increased for those 25 years and older. During this period, death rates for cancer and heart disease decreased. The largest increases in trauma deaths were in individuals in their fifth and sixth decades of life. Since 2000, the largest proportional increase (118%) in crude trauma deaths occurred in 54-year-olds. Overall, in 2010, trauma was the leading cause of death in individuals 46 years and younger. Trauma remains the leading cause of years of life lost., Results: Trauma is now the leading cause of death for individuals 46 years and younger. The largest increase in the number of trauma deaths and the highest crude number of trauma deaths occurred in baby boomers. Policy makers allocating resources should be made aware of the larger impact of trauma on our aging and burgeoning US population.

Background: Heart rate and systolic blood pressure are unreliable in geriatric trauma patients. Shock index (SI) (heart rate/systolic blood pressure) is a simple marker of worse outcomes after injury. The aim of this study was to assess the utility of SI in predicting outcomes. We hypothesized that SI predicts mortality in geriatric trauma patients., Methods: We performed a 4-year (2007-2010) retrospective analysis using the National Trauma Data Bank. Patients 65 years or older were included. Transferred patients, patients dead on arrival, missing vitals on presentation, and patients with burns and traumatic brain injury were excluded. A cutoff value of SI greater than or equal to 1 (sensitivity, 81%; specificity, 79%) was used to define hemodynamic instability. The primary outcome measure was mortality. Secondary outcome measures were need for blood transfusion, need for exploratory laparotomy, and development of in-hospital complications. Multiple logistic regressions were performed., Results: A total of 485,595 geriatric patients were reviewed, of whom 217,190 were included. The mean (SD) age was 77.7 (7.1) years, 60% were males, median Glasgow Coma Scale (GCS) score was 14 (range, 3-15), median Injury Severity Score (ISS) was 9 (range, 4-18), and mean (SD) SI was 0.58 (0.18). Three percent (n = 6,585) had an SI greater than or equal to 1. Patients with SI greater than or equal to 1 were more likely to require blood product requirement (p = 0.001), require an exploratory laparotomy (p = 0.01), and have in-hospital complications (p = 0.02). The overall mortality rate was 4.1% (n = 8,952). SI greater than or equal to 1 was the strongest predictor for mortality (odds ratio, 3.1; 95% confidence interval, 2.6-3.3; p = 0.001) in geriatric trauma patients. Systolic blood pressure (p = 0.09) and heart rate (p = 0.2) were not predictive of mortality., Conclusion: SI is an accurate and specific predictor of morbidity and mortality in geriatric trauma patients. SI is superior to heart rate and systolic blood pressure for predicting mortality in geriatric trauma patients. Geriatric trauma patients with SI greater than or equal to 1 should be transferred to a Level 1 trauma center., Level of Evidence: Prognostic/epidemiologic study, level III.

Background: Firearm control laws vary across the United States and remain state specific. The aim of this study was to determine the relationship between variation in states' firearm control laws and the risk of firearm-related injuries in pediatric population. We hypothesized that strict firearm control laws impact the incidence of pediatric firearm injury., Methods: All patients with trauma Ecodes and those 18 years or younger were identified from the 2009 Nationwide Inpatient Sample. Individual states' firearm control laws were evaluated and scored based on background checks on firearm sales, permit requirements, assault weapon and large-capacity magazine ban, mandatory child safety lock requirements, and regulations regarding firearms in college and workplaces. States were then dichotomized into strict firearm laws (SFLs) and non-strict firearm laws (non-SFLs) state based on median total score. The primary outcome measure was incidence of firearm injury. Data were compared between the two groups using simple linear regression analysis., Results: A total of 60,224 pediatric patients with trauma-related injuries across 44 states were included. Thirty-three states were categorized as non-SFL and 11 as SFL. Two hundred eighty-six (0.5%) had firearm injuries, of which 31 were self-inflicted. Mean firearm injury rates per 1,000 trauma patients was higher in the non-SFL states (mean [SD]: SFL, 2.2 [1.6]; non-SFL, 5.9 [5.6]; p = 0. 001). Being in a non-SFL state increased the mean firearm injury rate by 3.75 (β coefficient, 3.75; 95% confidence interval, 0.25-7.25; p = 0.036)., Conclusion: Children living in states with strict firearm legislation are safer. Efforts to improve and standardize national firearm control laws are warranted., Level of Evidence: Prognostic study, level III.

Background: One third of US adults are obese. The impact of obesity on outcomes after blunt traumatic injury has been studied with discrepant results. The aim of our study was to evaluate outcomes in morbidly obese patients after blunt trauma. We hypothesized that morbidly obese patients have adverse outcomes as compared with nonobese patients after blunt traumatic injury., Methods: We performed a retrospective analysis of all blunt trauma patients (≥18 years) using the National Trauma Data Bank for years 2007 to 2010. Patients with recorded comorbidity of morbid obesity (body mass index ≥ 40) were identified. Patients transferred, dead on arrival, and with isolated traumatic brain injury were excluded. Propensity score matching was used to match morbidly obese patients to non-morbidly obese patients (body mass index < 40) in a 1:1 ratio based on age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and systolic blood pressure on presentation. The primary outcome was mortality, and the secondary outcome was hospital complications., Results: A total of 32,780 patients (morbidly obese, 16,390; nonobese, 16,390) were included in the study. Morbidly obese patients were more likely to have in-hospital complications (odds ratio [OR], 1.8, 95% confidence interval [CI], 1.6-1.9), longer hospital stay (OR, 1.2; 95% CI, 1.1-1.3), and longer intensive care unit stay (OR, 1.15; 95% CI, 1.09-1.2). The overall mortality rate was 2.8% (n = 851). Mortality was higher in morbidly obese patients compared with the nonobese patients (3.0 vs. 2.2; OR, 1.4; 95% CI, 1.1-1.5)., Conclusion: In a cohort of matched patients, morbid obesity is a risk factor for the development of in-hospital complications and mortality after blunt traumatic injury. The results of our study call for attention through focused injury prevention efforts. Future studies are needed to help define the consequences of obesity that influence outcomes., Level of Evidence: Prognostic study, level III.