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Background: The American Association for the Surgery of Trauma Organ Injury Scale (OIS) Committee published the original pancreatic OIS in 1990 with the authors acknowledging at the time that the classification would need to undergo "continued refinement as clinical experience dictates." The current OIS overemphasizes injury location over ductal integrity; modifications are needed to improve concordance between OIS, therapy, and outcomes and promote accuracy in quality assessment and research., Methods: A subcommittee of the American Association for the Surgery of Trauma and invited experts in radiology and interventional gastroenterology were chosen. Contemporary literature was reviewed, and a standardized iterative and collegial process was used to arrive at consensus., Results: The pancreatic OIS is anatomically based on operative, radiographic, or pathologic findings. Major changes to the grading system include moving lacerations of the pancreatic head without ductal injury from Grade IV to Grade II. Injuries to the duct in the neck, body, or tail remain Grade III but are further subclassified to distinguish between deep parenchymal injuries without ductal interrogation, partial ductal injuries, and complete ductal transection. Grade IV injuries follow the same nomenclature but for injuries to the right of the portal vein or superior mesenteric vein. Grade V injuries are destructive injuries of the pancreatic head with nonviable parenchyma. These injuries are further subgraded based on ductal injuries., Conclusion: The pancreatic OIS schema is revised based on contemporary experience informed by the current understanding of outcomes and treatment, including operative management and outcomes. Increasing grades now more closely reflect increasing severity., (Copyright © 2025 American Association for the Surgery of Trauma.)

Abstract: The American Association for the Surgery of Trauma initially published the organ injury scaling for the kidney in 1989, which was subsequently updated in 2018. This current American Association for the Surgery of Trauma kidney organ injury scaling update incorporates the latest evidence in diagnosis and management of renal trauma and is based upon a multidisciplinary consensus. These changes reflect the near universal use of computed tomography for renal trauma evaluation and the widespread adoption of conservative management across all grades of renal trauma., (Copyright © 2025 American Association for the Surgery of Trauma.)

Background: The Modified Nutritional Risk in Critically Ill (mNUTRIC) score has been proposed as a tool to identify hospitalized patients at risk for malnutrition who may benefit from early enteral nutrition (EN) therapy., Objective: Our goal was to determine if mNUTRIC scores could predict, at time of intensive care unit admission, which mechanically ventilated trauma patients were at risk for malnutrition and might benefit from early EN, as indicated by reduced mortality., Methods: We conducted a retrospective chart review of all adult trauma patients requiring mechanical ventilation for at least 48 hours between 01/21/2012 and 12/31/2016, reviewing inpatient medical records, demographic data, disease markers, injury severity, and comorbidities. Bivariate statistics and multivariate regression analyses were used to investigate the correlation between time of EN initiation and mortality rates, as well as the relationship of mNUTRIC scores with EN commencement with early EN initiation being ≤48 hours and malnutrition risk mNUTRIC ≥5., Results: Among 931 patients reviewed, bivariate analysis showed higher mNUTRIC scores correlated with older, sicker patients and higher mortality. However, multivariate analysis revealed no significant association between higher mNUTRIC scores and increased mortality (OR 1.2, 95% CI 0.7-2.1, p=0.52). Although most patients received EN within 48 hours, there was no association between mNUTRIC score and timing of EN initiation after adjusting for demographic variables and illness severity., Conclusions: Our findings indicate that while the mNUTRIC score can effectively identify malnutrition risk, it does not meaningfully inform early EN initiation timing nor predict mortality in mechanically ventilated trauma patients., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (© 2024 The Authors.)

Introduction: There has been a substantial increase in the number of trauma centers (TCs) opened in the US over the past decade which coincided with population increases and policy changes. Our hypotheses were that new TC locations would likely be related to the socioeconomic profile of the surrounding locale-likely favoring higher-income areas-and that hospital ownership status may play a role in the distribution of new centers. Our aim was to use geographic information systems (GIS) analysis to evaluate the growth of an established regional TC and to delineate factors associated with the site chosen for new centers., Methods: ARC-GIS mapping software was utilized to generate a map of all TCs within two Florida metropolitan areas-Jacksonville and Miami. Hospital ownership was classified as for-profit (FP) or government, and opening dates were obtained from publicly available data. US census data (2020) was utilized to add sociodemographic data (race, income, insurance status) by zip code., Results: The majority of newer TCs opened in Duval/Clay and Dade/Broward counties were FP. GIS mapping demonstrated that 100% of new TCs demonstrated higher mean charges compared to established TC and were located in higher-income neighborhoods where residents were more likely to have health insurance with fewer African-American residents., Conclusions: Most TCs added to two of the largest metropolitan areas within Florida over the past decade were FP. These TCs demonstrated higher mean charges and tended to be located in areas of higher-income neighborhoods with better insured residents and fewer African-Americans. Such data suggest that more oversight is potentially needed to regulate and organize trauma system development to address trauma need rather than financial incentive alone., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: This manuscript provides a history of efforts by the American Public Health Association (APHA) Maternal and Child Health Section (MCH Section) Gun Violence Prevention Workgroup (GVP Workgroup) to promote gun violence prevention (GVP) as a key public health priority both within the MCH Section and APHA, and nationally., Description: The MCH Section established a gun violence prevention workgroup in response to the murders of twenty first-grade children and six adults at Sandy Hook Elementary School. This article presents an overview of the accomplishments and challenges of the MCH Section GVP Workgroup in a context of ever-increasing gun violence. As of 2020, firearms became the leading cause of death for U.S. children and teens., Assessment: Over the past decade, a small group of volunteers helped maintain GVP as one of the top priorities of both the MCH Section and APHA. Endorsement by the MCH Section and APHA leadership facilitated MCH Section GVP Workgroup efforts including organizing a national conference, developing scientific sessions for APHA annual meetings, establishing coalitions, and providing ongoing education and outreach to APHA members., Conclusion: The MCH Section GVP Workgroup helped to both elevate and maintain focus on GVP as a top priority of the MCH Section and APHA, indirectly impacting national efforts to promote a public health approach to GVP. The ongoing epidemic of firearm violence highlights the importance of continuing and strengthening this work. Individuals at other national, state or local organizations might look to the efforts and accomplishment of the MCH Section GVP Workgroup in pursuing critical issues within their own organizations., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

24/7 critical care staffing has become more commonplace, and their impact on resident training must be carefully considered. At our institution, the Critical Care Resource Intensivist (CCRI) model was implemented to provide in-house dedicated faculty responsible solely for the provision of critical care overnight. An anonymous survey was distributed to all general surgery residents to evaluate CCRI's impact on education and autonomy. Descriptive statistics were completed for quantitative data. Qualitative analysis of free text responses was completed to identify consensus themes. Responses from 26 residents demonstrated they associated CCRI with improved resident education, supervision, and patient care, without limiting autonomy. Qualitative analysis yielded 7 themes, reflecting improvements in patient care and safety, progression of care, operations and procedures, improved education, availability, and independence , but noted potential for conflict . Our findings show 24/7 dedicated intensivist staffing can enhance general surgery resident education without limiting autonomy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Little research has focused on assessing the mortality for fall height based on field-relevant categories like falls from greater than standing (FFGS), falls from standing (FFS), and falls from less than standing., Methods: This retrospective observational study included patients evaluated for a fall incident at an urban Level I Trauma Center or included in Medical Examiner's log from January 1, 2015, to June 31, 2017. Descriptive statistics characterized the sample based on demographic variables such as age, race, sex, and insurance type, as well as injury characteristics like relative fall height, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), traumatic brain injury, intensive care unit length of stay, and mortality. Bivariate analysis included Chi-square tests for categorical variables and Student t-tests for continuous variables. Subsequent multiple logistic regression modeled significant variables from bivariate analyses, including age, race, insurance status, fall height, ISS, and GCS., Results: When adjusting for sex, age, race, insurance, ISS, and GCS, adults ≥65 who FFS had 1.93 times the odds of mortality than those who FFGS. However, those <65 who FFGS had 3.12 times the odds of mortality than those who FFS. Additionally, commercial insurance was not protective across age groups., Conclusions: The mortality for FFS may be higher than FFGS under certain circumstances, particularly among those ≥65 y. Therefore, prehospital collection should include accurate assessment of fall height and surface (i.e., water, concrete). Lastly, commercial insurance was likely a proxy for industrial falls, accounting for the surprising lack of protection against mortality., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Severe trauma can induce systemic inflammation but also immunosuppression, which makes understanding the immune response of trauma patients critical for therapeutic development and treatment approaches. By evaluating the levels of 59 proteins in the plasma of 50 healthy volunteers and 1000 trauma patients across five trauma centers in the United States, we identified 6 novel changes in immune proteins after traumatic injury and further new variations by sex, age, trauma type, comorbidities, and developed a new equation for prediction of patient survival. Blood was collected at the time of arrival at Level 1 trauma centers and patients were stratified based on trauma level, tissues injured, and injury types. Trauma patients had significantly upregulated proteins associated with immune activation (IL-23, MIP-5), immunosuppression (IL-10) and pleiotropic cytokines (IL-29, IL-6). A high ratio of IL-29 to IL-10 was identified as a new predictor of survival in less severe patients with ROC area of 0.933. Combining machine learning with statistical modeling we developed an equation ("VIPER") that could predict survival with ROC 0.966 in less severe patients and 0.8873 for all patients from a five analyte panel (IL-6, VEGF-A, IL-21, IL-29, and IL-10). Furthermore, we also identified three increased proteins (MIF, TRAIL, IL-29) and three decreased proteins (IL-7, TPO, IL-8) that were the most important in distinguishing a trauma blood profile. Biologic sex altered phenotype with IL-8 and MIF being lower in healthy women, but higher in female trauma patients when compared to male counterparts. This work identifies new responses to injury that may influence systemic immune dysfunction, serving as targets for therapeutics and immediate clinical benefit in identifying at-risk patients., Competing Interests: CONFLICT OF INTEREST The authors declare no conflict of interest.

Background: In a large multicenter trial, The Parkland Grading Scale (PGS) for acute cholecystitis outperformed other grading scales and has a positive correlation with complications but is limited in its inability to preoperatively predict high-grade cholecystitis. We sought to identify preoperative variables predictive of high-grade cholecystitis (PGS 4 or 5)., Methods: In a six-month period, patients undergoing cholecystectomy at a single institution with prospectively graded PGS were analyzed. Stepwise logistic regression models were constructed to predict high-grade cholecystitis. The relative weight of the variables was used to derive a novel score, the Severe Acute Cholecystitis Score (SACS). This score was compared with the Emergency Surgery Acuity Score(ESS), American Association for the Surgery of Trauma (AAST) preoperative score and Tokyo Guidelines (TG) for their ability to predict high-grade cholecystitis. Severe Acute Cholecystitis Score was then validated using the database from the AAST multicenter validation of the grading scale for acute cholecystitis., Results: Of the 575 patients that underwent cholecystectomy, 172 (29.9%) were classified as high-grade. The stepwise logistic regression modeling identified seven independent predictors of high-grade cholecystitis. From these variables, the SACS was derived. Scores ranged from 0 to 9 points with a C statistic of 0.76, outperforming the ESS ( C statistic of 0.60), AAST (0.53), and TG (0.70) ( p < 0.001). Using a cutoff of 4 or more on the SACS correctly identifies 76.2% of cases with a specificity of 91.3% and a sensitivity of 40.7%. In the multicenter database, there were 464 patients with a prospectively collected PGS. The C statistic for SACS was 0.74. Using the same cutoff of 4, SACS correctly identifies 71.6% of cases with a specificity of 83.8% and a sensitivity of 52.2%., Conclusion: The Severe Acute Cholecystitis Score can preoperatively predict high-grade cholecystitis and may be useful for counseling patients and assisting in surgical decision making., Level of Evidence: Diagnostic Test/Criteria; Level III., (Copyright © 2024 American Association for the Surgery of Trauma.)

Background: Musculoskeletal discomfort is widely experienced by surgeons across multiple surgical specialties. Developing technologies and new minimally invasive techniques add further complexity and ergonomic stressors. These stressors differentially affect male and female surgeons, but little is known about the role these sex disparities play in surgical ergonomic stress. We reviewed existing literature to better understand how ergonomic stress varies between male and female surgeons., Study Design: A literature search was performed via PubMed including but not limited to the following topics: ergonomics, surgeons, female surgeons, women surgeons, pregnancy, and operating room. A review of available quantitative data was performed., Results: Female surgeons endure more pronounced ergonomic discomfort than their male counterparts, with added ergonomic stress associated with pregnancy., Conclusions: A 4-fold method is proposed to overcome ergonomic barriers, including (1) improved education on prevention and treatment of ergonomic injury for active surgeons and trainees, (2) increased departmental and institutional support for ergonomic solutions for surgeons, (3) partnerships with industry to study innovative ergonomic solutions, and (4) additional research on the nature of surgical ergonomic challenges and the differential effects of surgical ergonomics on female surgeons., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Individuals seeking certification as a board certified behavior analyst (BCBA) by the Behavior Analyst Certification Board (BACB) must meet certain eligibility requirements. In addition to passing the BCBA examination, such requirements include completion of a master's degree, behavior-analytic coursework, and supervised practical fieldwork. In accruing fieldwork hours, trainees must be provided with the opportunity to complete unrestricted activities. The BACB defines unrestricted activities as ". . . those that are most likely to be performed by a BCBA," and requires that 60% of fieldwork hours are comprised of these activities (BACB, 2022b). Fieldwork hours may be accrued across a number of different host sites (e.g., hospital units, schools, community locations), with each host site having different day-to-day responsibilities affecting how these opportunities are provided. Therefore, exploration of the provision of these opportunities and the barriers to providing these opportunities is warranted. The current study sought to determine the current practices involved in provision of opportunities to gain fieldwork experience hours towards BCBA certification; in particular, practices related to unrestricted fieldwork activities. Results indicate that, although unrestricted learning opportunities are often provided to trainees, contingencies present within the day-to-day operations of a clinical environment can be hampering. A discussion of the implications of these barriers and potential solutions are included., Competing Interests: Conflicts of InterestWe have no conflicts of interest to disclose., (© The Author(s) 2024.)

Background: Gun-related injury is now the number one cause of death in pediatric trauma patients. Many hospitals lack dedicated forensic nurses or updated protocols for handling ballistic evidence. Evidence not collected, handled improperly, or misplaced may deny a victim the basic human right to justice., Objective: This article aims to describe an initiative to highlight the importance of proper management of ballistic evidence and to educate medical providers on best practices for the documentation, handling, removal, and transfer of ballistic evidence., Methods: After discovering 24 "orphaned" bullets and bullet fragments in our hospital that had not been turned over to law enforcement, we sought to turn in evidence to the proper authorities and implement protocols to prevent this error in the future. New protocols were written by forensic staff, and education on new protocols was provided via in-person training, grand rounds, emails, and other collaborative initiatives., Results: Evidence was matched to police reports using the patient name and date of birth on evidence labels. The median (interquartile range [IQR]) time of lost ballistic evidence was 1,397 (903, 1604) days, with the oldest bullet removed in 2015. All bullets were successfully returned to law enforcement with a median (IQR) time from bullet discovery to collection of 78 (78, 174) days., Conclusions: Ballistic evidence handling protocols are essential for all hospitals. Dedicated, trained forensic staff should be employed to ensure proper evidence handling., Competing Interests: The authors declare no conflict of interest including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest., (Copyright © 2024 Society of Trauma Nurses.)

Background: Type II workplace violence in health care, perpetrated by patients/clients toward home healthcare nurses, is a serious health and safety issue. A significant portion of violent incidents are not officially reported. Natural language processing can detect these "hidden cases" from clinical notes. In this study, we computed the 12-month prevalence of Type II workplace violence from home healthcare nurses' clinical notes by developing and utilizing a natural language processing system., Methods: Nearly 600,000 clinical visit notes from two large U.S.-based home healthcare agencies were analyzed. The notes were recorded from January 1, 2019 to December 31, 2019. Rule- and machine-learning-based natural language processing algorithms were applied to identify clinical notes containing workplace violence descriptions., Results: The natural language processing algorithms identified 236 clinical notes that included Type II workplace violence toward home healthcare nurses. The prevalence of physical violence was 0.067 incidents per 10,000 home visits. The prevalence of nonphysical violence was 3.76 incidents per 10,000 home visits. The prevalence of any violence was four incidents per 10,000 home visits. In comparison, no Type II workplace violence incidents were recorded in the official incident report systems of the two agencies in this same time period., Conclusions and Application to Practice: Natural language processing can be an effective tool to augment formal reporting by capturing violence incidents from daily, ongoing, large volumes of clinical notes. It can enable managers and clinicians to stay informed of potential violence risks and keep their practice environment safe.

Level of Evidence: Literature synthesis and expert opinion, Level V., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Anthracyclines such as doxorubicin (Dox) are widely used to treat a variety of adult and childhood cancers, however, a major limitation to many of these compounds is their propensity for inducing heart failure. A naturally occurring polyphenolic compound such as Ellagic acid (EA) has been shown by our laboratory to mitigate the cardiotoxic effects of Dox, however, the effects of EA on cancer cell viability have not been established. In this study, we explored the effects of EA alone and in combination with Dox on cancer cell viability and tumorigenesis. Herein, we show that EA induces cell cycle exit and reduces proliferation in colorectal cancer (HCT116) and breast adenocarcinoma cells (MCF7). We show that EA promotes cell cycle exit by a mechanism that inhibits mitochondrial dynamics protein Drp-1. EA treatment of HCT116 and MCF7 cells resulted in a hyperfused mitochondrial morphology that coincided with mitochondrial perturbations including loss of mitochondrial membrane potential, impaired respiratory capacity. Moreover, impaired mitochondrial function was accompanied by a reduction in cell cycle and proliferation markers, CDK1, Ki67, and Cyclin B. This resulted in a reduction in proliferation and widespread death of cancer cells. Furthermore, while Dox treatment alone promoted cell death in both HCT116 and MCF7 cancer cell lines, EA treatment lowered the effective dose of Dox to promote cell death. Hence, the findings of the present study reveal a previously unreported anti-tumor property of EA that impinges on mitochondrial dynamics protein, Drp-1 which is crucial for cell division and tumorigenesis. The ability of EA to lower the therapeutic threshold of Dox for inhibiting cancer cell growth may prove beneficial in reducing cardiotoxicity in cancer patients undergoing anthracycline therapy., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The role of emergency department resuscitative thoracotomy (EDT) in traumatically injured children has not been elucidated. We aimed to perform a systematic review and create evidence-based guidelines to answer the following PICO (population, intervention, comparator, and outcome) question: should pediatric patients who present to the emergency department pulseless (with or without signs of life [SOL]) after traumatic injuries (penetrating thoracic, penetrating abdominopelvic, or blunt) undergo EDT (vs. no EDT) to improve survival and neurologically intact survival?, Methods: Using Grading of Recommendations Assessment, Development and Evaluation methodology, a group of 12 pediatric trauma experts from the Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma assembled to perform a systematic review. A consensus conference was conducted, a database was queried, abstracts and manuscripts were reviewed, data extraction was performed, and evidence quality was determined. Evidence tables were generated, and the committee voted on guideline recommendations., Results: Three hundred three articles were identified. Eleven studies met the inclusion criteria and were used for guideline creation, providing 319 pediatric patients who underwent EDT. No data were available on patients who did not undergo EDT. For each PICO, the quality of evidence was very low based on the serious risk of bias and serious or very serious imprecision., Conclusion: Based on low-quality data, we make the following recommendations. We conditionally recommend EDT when a child presents pulseless with SOL to the emergency department following penetrating thoracic injury, penetrating abdominopelvic injury and after blunt injury if emergency adjuncts point to a thoracic source. We conditionally recommend against EDT when a pediatric patient presents pulseless without SOL after penetrating thoracic and penetrating abdominopelvic injury. We strongly recommend against EDT in the patient without SOL after blunt injury., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

At a large academic level 1 trauma center, an additional resource was added at night, the Critical Care Resource Intensivist (CCRI), which is a multi-disciplinary group of fellowship trained intensivists. Prior to implementation of this additional resource, concurrent to implementation and one-year post implementation, critical care (CC) nurses that provide care in the surgical, neurologic, medical, and cardiac intensive care units (ICU) were anonymously surveyed to evaluate the CCRI model from a nursing perspective. Survey results were aggregated via an electronic cloud-based survey tool. Our goal was to obtain qualitative data to inform hypothesis generation and quality improvement questions. As such, we collected free-text answers to the questions, "Do you ever have concerns about availability of faculty in the ICU?" and, "Do you have any suggestions or comments after implementation of CCRI?" Answers were categorized into pre- and postCCRI strata. When coding the data, the investigators found a total of 9 themes that connected all the free-text survey. The themes included faculty accessibility, nurse safety, satisfaction, continuum of care and patient safety, to name a few. CCRI was uniformly and unanimously felt to improve patient care and decrease provider stress, because of improved availability and responsiveness of cc-faculty. The need to expand the CCRI model across institutional campuses was also stated clearly within their responses. These surveys demonstrate the strong support for the CCRI model by CC nurse providers. Further studies should investigate the effects of CCRI on nurse provider burnout and turnover, especially given recent crises in nursing., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: There is significant data in the medical and surgical literature supporting the correlations between positive volume balance and negative outcomes such as AKI, prolonged mechanical ventilation, intensive care unit and hospital length of stay and increased mortality., Methods: This single-center, retrospective chart review included adult patients identified from a Trauma Registry database. The primary outcome was the total ICU LOS. Secondary outcomes include hospital LOS, ventilator-free days, incidence of compartment syndrome, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT), and days of vasopressor therapy., Results: In general, baseline characteristics were similar between groups with the exception of mechanism of injury, FAST exam, and disposition from the ED. The ICU LOS was shortest in the negative fluid balance and longest in the positive fluid balance group (4 days vs 6 days, P = .001). Hospital LOS was also shorter in the negative balance group than that of the positive balance group (7 days vs 12 days, P < .001). More patients in the positive balance group experienced acute respiratory distress syndrome compared to the negative balance group (6.3% vs 0%, P = .004). There was no significant difference in the incidence of renal replacement therapy, days of vasopressor therapy, or ventilator-free days., Discussion: A negative fluid balance at seventy-two hours was associated with a shorter ICU and hospital LOS in critically ill trauma patients. Our observed correlation between positive volume balance and total ICU days merits further exploration with prospective, comparative studies of lower volume resuscitation to key physiologic endpoints compared with routine standard of care.

Introduction: The American Association for the Surgery of Trauma Colon Organ Injury Scale (OIS) was updated in 2020 to include a separate OIS for penetrating colon injuries and included imaging criteria. In this multicenter study, we describe the contemporary management and outcomes of penetrating colon injuries and hypothesize that the 2020 OIS system correlates with operative management, complications, and outcomes., Methods: This was a retrospective study of patients presenting to 12 Level 1 trauma centers between 2016 and 2020 with penetrating colon injuries and Abbreviated Injury Scale score of <3 in other body regions. We assessed the association of the new OIS with surgical management and clinical outcomes and the association of OIS imaging criteria with operative criteria. Bivariate analysis was done with χ 2 , analysis of variance, and Kruskal-Wallis, where appropriate. Multivariable models were constructed in a stepwise selection fashion., Results: We identified 573 patients with penetrating colon injuries. Patients were young and predominantly male; 79% suffered a gunshot injury, 11% had a grade V destructive injury, 19% required ≥6 U of transfusion, 24% had an Injury Severity Score of >15, and 42% had moderate-to-large contamination. Higher OIS was independently associated with a lower likelihood of primary repair, higher likelihood of resection with anastomosis and/or diversion, need for damage-control laparotomy, and higher incidence of abscess, wound infection, extra-abdominal infections, acute kidney injury, and lung injury. Damage control was independently associated with diversion and intra-abdominal and extra-abdominal infections. Preoperative imaging in 152 (27%) cases had a low correlation with operative findings ( κ coefficient, 0.13)., Conclusion: This is the largest study to date of penetrating colon injuries and the first multicenter validation of the new OIS specific to these injuries. While imaging criteria alone lacked strong predictive value, operative American Association for the Surgery of Trauma OIS colon grade strongly predicted type of interventions and outcomes, supporting use of this grading scale for research and clinical practice., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Few studies have examined the impact of interstate differences in firearm laws on state-level firearm mortality. We aim to study the association between neighboring states' firearm legislation and firearm-related crude death rate (CDR)., Methods: The CDC Web-based Injury Statistics Query and Reporting System was queried for adult all-intent (accidental, suicide, and homicide) firearm-related CDR among the 50 states from 2012 to 2020. States were divided into five cohorts based on the Giffords Law Center Annual Gun Law Scorecard, and two groups were constructed: Strict (A, B, C) and Lenient (D, F). We examined the effect of (1) a single incongruent neighbor, defined as "Different" if the state is bordered by ≥1 state with a grade score difference >1, and (2) the average grade of all neighboring states, defined as "Different" if the average of all neighboring states resulted in a grade score difference >1., Results: Strict states with similar average neighbors had significantly lower CDR compared with Strict states with different average neighbors (2.98 [1.91-5.06] vs. 3.87 [2.37-5.94], p = 0.02), while Lenient states with similar average neighbors had significantly higher CDR compared with Lenient states with different average neighbors (6.02 [4.56-8.11] vs. 4.7 [3.95-5.35], p = 0.002). Lenient states surrounded by all similar Lenient states had the highest CDR, which was significantly higher than Lenient states with ≥1 different neighbor (6.52 [5.09-8.96] vs. 5.19 [3.85-6.61], p < 0.001). However, Strict states with ≥1 different neighbor did not have higher CDR compared with Strict states surrounded by all similar Strict states (3.39 [2.17-5.35] vs. 3.14 [1.91-5.38], p = 0.5)., Conclusion: We report a lopsided neighboring effect whereby Lenient states may benefit from at least one Strict neighbor, while Strict states may be adversely affected only when surrounded by mostly Lenient neighbors. These findings may assist policymakers regarding the efficacy of their own state's legislation in the context of incongruent neighboring states., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patients with right upper quadrant pain are often imaged using multiple modalities with no established gold standard. A single imaging study should provide adequate information for diagnosis., Methods: A multicenter study of patients with acute cholecystitis was queried for patients who underwent multiple imaging studies on admission. Parameters were compared across studies including wall thickness (WT), common bile duct diameter (CBDD), pericholecystic fluid and signs of inflammation. Cutoff for abnormal values were 3 mm for WT and 6 mm for CBDD. Parameters were compared using chi-square tests and Intra-class correlation coefficients (ICC)., Results: Of 861 patients with acute cholecystitis, 759 had ultrasounds, 353 had CT and 74 had MRIs. There was excellent agreement for wall thickness (ICC = 0.733) and bile duct diameter (ICC = 0.848) between imaging studies. Differences between wall thickness and bile duct diameters were small with nearly all <1 mm. Large differences (>2 mm) were rare (<5%) for WT and CBDD., Conclusions: Imaging studies in acute cholecystitis generate equivalent results for typically measured parameters., Competing Interests: Declaration of competing interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. None of the authors has a conflict of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia., Methods: Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used., Results: Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality., Conclusion: We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia., Level of Evidence: Systematic Review/Meta-analysis; Level IV., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: We aim to study the association between state child access prevention (CAP) and overall firearm laws with pediatric firearm-related mortality., Methods: The Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System was queried for pediatric (aged < 18 y) all-intent (accidental, suicide, and homicide) firearm-related crude death rates (CDRs) among the 50 states from 1999 to 2019. States were into three groups: Always CAP (throughout the 20-year period), Never CAP, and New CAP (enacted CAP during study period). We used the Giffords Law Center Annual Gun Law Scorecard (A, B, C, D, F) to group states into strict (A, B) and lenient (C, D, F) firearm laws. A scatter plot was constructed to display state CDR based on CAP laws by year. The top 10 states by CDR per year were tabulated based on CAP law status. Wilcoxon rank-sum was used to compare CDR between strict and lenient scorecard states in 2019., Results: There were 12 Always CAP, 21 Never CAP, and 17 New CAP states from 1999 to 2019. No states changed from CAP laws to no CAP laws. Never CAP and New CAP states dominated the high outliers in CDR compared to Always CAP. The top 10 states with the highest CDR per year were most commonly Never CAP. Strict firearm laws states had lower median CDR in 2019 than lenient states (0.79 [0-1.67] versus 2.59 [1.66-3.53], P = 0.007)., Conclusions: Stricter overall gun laws are associated with three-fold lower all-intent pediatric firearm-related deaths. For 2 decades, the 10 states with the highest CDR were almost universally those without CAP laws. Our findings support the RAND Gun Policy in America initiative's claims on the importance of CAP laws in reducing suicide, unintentional deaths, and violent crime among children, but more research is needed., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Small bowel obstruction (SBO) is a common disease affecting all segments of the population, including the frail elderly. Recent retrospective data suggest that earlier operative intervention may decrease morbidity. However, management decisions are influenced by surgical outcomes. Our goal was to determine the current surgical management of SBO in older patients with particular attention to frailty and the timing of surgery., Study Design: A retrospective review of patients over the age of 65 with a diagnosis of bowel obstruction (ICD-10 K56*) using the 2016 National Inpatient Sample (NIS). Demographics included age, race, insurance status, medical comorbidities, and median household income by zip code. Elixhauser comorbidities were used to derive a previously published frailty score using the NIS dataset. Outcomes included time to operation, mortality, discharge disposition, and hospital length of stay. Associations between demographics, frailty, timing of surgery, and outcomes were determined., Results: 264,670 patients were included. Nine percent of the cohort was frail; overall mortality was 5.7%. Frail had 1.82 increased odds of mortality (95% CI 1.64-2.03). Hospital LOS was 1.6 times as long for frail patients; a quarter of the frail were discharged home. Frail patients waited longer for surgery (3.58 days vs 2.44 days; p < 0.001). Patients transferred from another facility had increased mortality (aOR 1.58; 95% CI 1.36-1.83). There was an increasing mortality associated with a delay in surgery., Conclusion: Patients with frailty and SBO have higher mortality, more frequent discharge to dependent living, longer hospital length of stay, and longer wait to operative intervention. Mortality is also associated with male gender, black race, transfer status from another facility, self-pay status, and low household income. Every day in delay in surgical intervention for those who underwent operations led to higher mortality. If meeting operative indications, older patients with bowel obstruction have a higher chance of survival if they undergo surgery earlier., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Cardiovascular disease is the leading cause of morbidity and mortality worldwide. However, sex differences can impact differently the etiology and outcome of cardiovascular disease when comparing men and women. Women have unique genetic and hormonal risk factors that can be associated with the development of cardiovascular diseases. Furthermore, certain phenotypes of cardiovascular diseases are more prevalent to women. Molecular clocks control circadian rhythms of different physiological systems in our body, including the cardiovascular system. Increased evidence in recent years points to a link between cardiovascular disease and regulation by circadian rhythms. However, the difference between circadian regulation of cardiovascular disease in women and men is poorly understood. In this review, we highlight the recent advances in circadian-regulated cardiovascular diseases with a specific focus on the pathogenesis of heart disease in women. Understanding circadian-regulated pathways and sex-specific differences between men and women may contribute to better diagnosis and development of sex-targeted interventions to better treat cardiovascular diseases.

Pediatric firearm violence carries significant morbidity and mortality. Studies targeting children ≤14 years are limited. Our goal was to study the distribution and determinants of GSWs in the pediatric population. We performed a retrospective review of children ≤14 years presenting with GSWs at this level 1 trauma center. This cohort was split into younger children, 0-12 years, and older children, 13-14 years. Summary and bivariate statistics were calculated using Stata v10. 142 patients (68.3% black, 76.7% male) were identified. Injuries more often occurred at home (39.6%) by family or friends (60.7%). Older children often suffered handgun injuries (85.5%) and more often were sent immediately to the OR on presentation (29.2%). Younger children more often suffered from air-gun (50%) and pistols (40%). Younger children more commonly had blood transfusions (9.4%) compared to exploratory laparotomy in older children (13.5%). The most common disposition from the ED was home (36.2%). Descriptive data entailing incident specifics such as time of injury and CPS involvement were frequently missing in the healthcare record. Older children were more likely to be injured by strangers, have longer lengths of stay especially associated with surgical operations, and have a disposition of immediate arrest compared to their younger cohort. Consequently, this group may benefit from interventions typically aimed at older patients such as violence intervention programs. When available, differences in demographics and outcomes were identified which could shape novel prevention strategies for firearm injury., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

In 2020, the American Association for the Surgery of Trauma (AAST) published a revision of the organ injury scale (OIS) for bowel injuries. The update included for the first time a separate OIS for penetrating colon injuries as well as imaging criteria. To validate the new OIS and its correlation with outcomes, we performed a retrospective review of patients with penetrating colon injuries (AIS<3 in other body regions) between 2016 and 2020 at a single institution. Sixty-six patients met inclusion criteria. Most were young (29 years median) and male (90%). All underwent operative intervention and 23 (34%) had pre-operative imaging. Imaging grade was higher than operative grade in 11 patients (48%). Higher AAST operative grade was associated with a higher likelihood of resection and anastomosis or colostomy, need for damage control laparotomy, and development of intra-abdominal abscess and acute kidney injury. A multicenter study is underway to confirm these findings.

Introduction: Ownership may influence trauma center (TC) location. For-profit (FP) TCs require a favorable payor mix to thrive, whereas not-for-profit (NFP) centers may rely on government funding, grants, and patient volume. We hypothesized that the demographics of trauma patients would be different for NFP and FP TCs due to ownership type. We also hypothesized that these demographic differences might be associated with outcomes such as length of stay, reported complications, and mortality., Methods: We used the Florida Agency for Health Care Administration (AHCA) 2016-2017 inpatient dataset to examine differences in outcomes by trauma center ownership type. Negative binomial and logistical regression was used to compare trauma ownership, length of stay (LOS), reported complications, and mortality of severely injured nonelderly adult trauma patients., Results: Our study analyzed risk factors and outcomes for 10,700 trauma alert patients. Patients treated at FP TCs were less likely to be Black (OR 0.70, 95% CI: 0.62-0.78), to be uninsured (OR 0.40, 95% CI 0.36-0.45), have Medicare (OR 0.53, 95% CI 0.43-0.66), or Medicaid (OR 0.57, 95% CI 0.50-0.65) (all P < 0.001). Patients treated at FP centers were less likely to have comorbidities (OR 0.89, 95% CI 0.82-0.96) and were associated with a longer LOS (0.10, 95% 0.05-0.15, P < 0.001) in nonelderly adult trauma patients. FP TCs were associated with fewer reported complications (OR 0.83, 95% CI 0.74-0.94) and were associated with a higher likelihood of mortality in nonelderly adults (OR 1.70, 95% CI 1.35-2.12, P < 0.001)., Conclusions: Among this cohort of severe International Classification of Diseases-based injury severity score (ICISS) patients, complications were less likely, but LOS and mortality were increased among FP TC patients. FP centers cared for fewer patients who were Black, uninsured, or who were Medicare/Medicaid/noncommercial insurance., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Grading systems for acute cholecystitis are essential to compare outcomes, improve quality, and advance research. The American Association for the Surgery of Trauma (AAST) grading system for acute cholecystitis was only moderately discriminant when predicting multiple outcomes and underperformed the Tokyo guidelines and Parkland grade. We hypothesized that through additional expert consensus, the predictive capacity of the AAST anatomic grading system could be improved., Methods: A modified Delphi approach was used to revise the AAST grading system. Changes were made to improve distribution of patients across grades, and additional key clinical variables were introduced. The revised version was assessed using prospectively collected data from an AAST multicenter study. Patient distribution across grades was assessed, and the revised grading system was evaluated based on predictive capacity using area under receiver operating characteristic curves for conversion from laparoscopic to an open procedure, use of a surgical "bail-out" procedure, bile leak, major complications, and discharge home. A preoperative AAST grade was defined based on preoperative, clinical, and radiologic data, and the Parkland grade was also substituted for the operative component of the AAST grade., Results: Using prospectively collected data on 861 patients with acute cholecystitis the revised version of the AAST grade has an improved distribution across all grades, both the overall grade and across each subscale. A higher AAST grade predicted each of the outcomes assessed (all p ≤ 0.01). The revised AAST grade outperformed the original AAST grade for predicting operative outcomes and discharge disposition. Despite this improvement, the AAST grade did not outperform the Parkland grade or the Emergency Surgery Score., Conclusion: The revised AAST grade and the preoperative AAST grade demonstrated improved discrimination; however, a purely anatomic grade based on chart review is unlikely to predict outcomes without addition of physiologic variables. Follow-up validation will be necessary., Level of Evidence: Diagnostic Test or Criteria, Level IV., (Copyright © 2021 American Association for the Surgery of Trauma.)

We believe this to be the first case report of jejunosigmoid bypass harboring small bowel adenocarcinoma. The mechanism of malignant degeneration could be similar to that of carcinogenesis of ureterosigmoidostomy that is of historical interest. This case represents an example of why it is imperative for surgeons to be diligent in their preparation and workup of a patient before a complex operation, especially in patients with peculiar or unknown surgical histories.

Background: Direct correlations between platelet adenosine diphosphate (ADP) and arachidonic acid (AA) receptor inhibition have been described in the traumatic brain injury (TBI) population. Our goal was to evaluate the percent inhibition of ADP receptor inhibition (ADPri) and AA receptor inhibition (AAri) receptors in non-TBI patients and correlate injury severity and outcomes., Methods: We performed a retrospective review of non-TBI patients admitted to our trauma center, who received thromboelastography with platelet mapping prior to blood transfusion. Exclusion criteria included patients younger than 18 years, current antiplatelet therapy, or history of renal failure. Univariate descriptive statistics and bivariate comparisons were performed on patient demographic and outcomes. Multivariable linear regression models were constructed to quantify any association between ADPri and AAri with injury outcomes. High ADP inhibition was defined >20% and high AA inhibition >7%., Results: 117 patients met inclusion criteria. Mean age was 53 years with 61% male. Mean ADPri was 64% and AAri 42%. On bivariate analysis, no statistically significant differences with respect to injury severity measures or outcomes were identified. On multivariable linear regression, AAri was associated with longer hospital length of stay., Discussion: There was a high degree of platelet dysfunction in this cohort of severely injured patients without TBI. Despite this, the only correlation identified between injury severity and outcomes was AAri correlating with hospital length of stay. Irrespective of injury severity or outcomes, these patients' results were far from reported "normal" values. Further, research is needed to determine the significance and clinical implications of thromboelastography with platelet mapping use in trauma care.

Background: For-profit (FP) trauma centers (TCs) charge more for trauma care than not-for-profit (NFP) centers. We sought to determine charges, length of stay (LOS), and complications associations with TC ownership status (FP, NFP, and government) for three diagnoses among patients with overall low injury severity., Methods: Adult patients treated at TCs with an International Classification of Diseases-based injury severity score (ICISS) survival probability ≥ 0.85 were identified. Only those who with a principal diagnosis of femur, tibial or rib fractures were included., Results: Total charges were significantly higher at FP centers than NFP and lower at government centers (89.6% and -12.8%, respectively). FP TCs had a 12.5% longer LOS and government TCs had a 20.4% longer LOS than NFP TCs., Conclusion: Patients presenting to FP TCs with mild/moderate femur, tibial, or rib fractures experienced higher charges and increased LOS compared with government or NFP centers. There was no difference in overall complication rates., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The current national burden of emergency general surgery (EGS) illnesses and the extent of surgeon involvement in the care of these patients remain largely unknown. To inform needs assessments, research, and education, we sought to: (1) translate previously developed International Classification of Diseases (ICD), 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes representing EGS conditions to ICD 10th Revision, CM (ICD-10-CM) codes and (2) determine the national burden of and assess surgeon involvement across EGS conditions., Methods: We converted ICD-9-CM codes to candidate ICD-10-CM codes using General Equivalence Mappings then iteratively refined the code list. We used National Inpatient Sample 2016 to 2017 data to develop a national estimate of the burden of EGS disease. To evaluate surgeon involvement, using Wisconsin Hospital Association discharge data (January 1, 2016 to June 30, 2018), we selected adult urgent/emergent encounters with an EGS condition as the principal diagnosis. Surgeon involvement was defined as a surgeon being either the attending provider or procedural physician., Results: Four hundred and eighty-five ICD-9-CM codes mapped to 1,696 ICD-10-CM codes. The final list contained 985 ICD-10-CM codes. Nationally, there were 2,977,843 adult patient encounters with an ICD-10-CM EGS diagnosis. Of 94,903 EGS patients in the Wisconsin Hospital Association data set, most encounters were inpatient as compared with observation (75,878 [80.0%] vs. 19,025 [20.0%]). There were 57,780 patients (60.9%) that underwent any procedure. Among all Wisconsin EGS patients, most had no surgeon involvement (64.9% [n = 61,616]). Of the seven most common EGS diagnoses, surgeon involvement was highest for appendicitis (96.0%) and biliary tract disease (77.1%). For the other five most common conditions (skin/soft tissue infections, gastrointestinal hemorrhage, intestinal obstruction/ileus, pancreatitis, diverticular disease), surgeons were involved in roughly 20% of patient care episodes., Conclusion: Surgeon involvement for EGS conditions ranges from highly likely (appendicitis) to relatively unlikely (skin/soft tissue infections). The wide range in surgeon involvement underscores the importance of multidisciplinary collaboration in the care of EGS patients., Level of Evidence: Prognostic/epidemiological, Level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Background: Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients., Methods: An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality., Results: Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77)., Conclusion: Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk., Level of Evidence: Prognostic, level II., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Trauma patients may initially be evaluated at non-trauma centers. This may cause a delay in treatment, which could affect their outcome. Additionally, advanced imaging may be performed which may be suboptimal or unnecessary, increase time to transfer, or unable to be viewed when the patient reaches a trauma center increasing the delays to treatment or need for repeat imaging. Rapid identification and transfer to definitive trauma care, minimizing unnecessary delays should be the priority., Methods: The trauma registry at a regional Level 1 Adult/Pediatric Trauma center was queried for transferred trauma patients over a 3-y period. A retrospective review was performed. Transferred trauma patients were compared prior to an expedited transfer protocol to after implementation. Demographics, mechanism of injury, injury severity score, computerized tomography scans performed prior to transfer, mortality, hospital and intensive care unit length of stay were compared using bivariate and multivariable regression statistics where appropriate., Results: Transferred trauma patients were identified, 683 in the pre-protocol group and 821 in the post-protocol group, an increase of 16.8%. There were no differences in age, sex, injury severity score, mechanism of injury, mortality, hospital, or intensive care unit length of stay (LOS) throughout the study period. There was a significant decrease in time to transfer (263 min ± 222 versus 227 ± 189, P < 0.001) and computerized tomography scans performed prior to transfer (Head 47% versus 32%, C-spine 36% versus 23%, Thorax 22% versus 16%, Abdomen/Pelvis 24% versus 14%, all P values <0.001 except CT Thorax). Interestingly, the rate of underinsured patients did not increase (21% versus 25%, P = 0.05). Risk-adjusted mortality and hospital LOS also did not change during the study period., Conclusions: After implementation of an expedited trauma transfer protocol to a regional Level 1 trauma center there was an associated reduced time of arrival to definitive care and decreased advanced imaging done prior to transfer. However, there was no associated decrease in mortality or LOS among transferred patients. Further studies examining prehospital transport or hospital choice decisions and subsequent care provided at non-trauma facilities regarding imaging obtained, care rendered, and transfer decisions can be explored., (Copyright © 2021. Published by Elsevier Inc.)

Substance use disorders (SUDs) and high incidence of infectious diseases are both critical public health issues. Among patients who use a venous access device (VAD) in home care settings, SUDs may play a role in increasing their risk of having a concurrent infectious disease. This study examined the association of SUD with infectious diseases among adult home healthcare patients with a VAD. We identified adult patients with an existing VAD who were admitted to a home healthcare agency August 1, 2017-July 31, 2018 from the electronic health records of a large Medicare-certified agency. Four serious infectious diseases (endocarditis, epidural abscess, septic arthritis, and osteomyelitis) and SUD related to injectable drugs were identified using relevant ICD-10 codes. Multiple logistic regression was performed to examine the association. Of 416 patients with a VAD, 12% (n = 50) had at least one diagnosis of a serious infectious disease. The percentage of patients who had a serious infectious disease was 40% among those with SUDs, compared with only 11% among those without SUDs. After adjusting for age and sex, the odds of having a serious infectious disease was 3.52 times greater for those with SUDs compared with those without (odds ratio [95% confidence interval], 4.52 [1.48-13.79], n = .008). Our findings suggest that home healthcare patients with a VAD and a documented SUD diagnosis may have an increased risk of having a concurrent serious infectious disease. Therefore, patients with an SUD and a VAD would need more attention from home healthcare providers to prevent a serious infectious disease. Further research is suggested on modalities of care for individuals with an SUD and VAD to reduce the incidence of infectious diseases so that care can be delivered safely and efficiently in a home healthcare setting., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Halo vest immobilization (HVI) remains an important treatment option for occipital-cervical injuries. It provides the surgeon with a safe and effective medical treatment options for challenging patients. The aim of this study was to evaluate the safety of HVI in these patients. Methods: This retrospective study identified adult patients treated with Halo vests immobilization (HVI) for acute cervical spine injury at our metropolitan level 1 trauma center from 2013 to 2017. This heterogenous cohort included 67 consecutive patients with acute cervical spine injury secondary to trauma or iatrogenic injury following surgical intervention with a mean age of 52 and a mean injury severity score (ISS) of 18. Forty-six percent of patients were treated with HVI as an adjunct therapy to surgical fixation (both short- and long-term immobilization), 45% of patients were treated with HVI as a primary medical treatment, and 9% of patients were treated with HVI instead of failed conservative medical treatment, such as cervical braces. Results: Pneumonia during the initial hospital stay was the most common complication (25%), followed by the correction of loose pins (22%) and pin site infections (18%). Overall, 51% of patients experienced at least one of these complications. There were significant associations between low initial GCS scores and the development of pneumonia (p < 0.001), high ISS scores and the development of pneumonia (p < 0.01), and duration of HVI and the occurrence of loose pins (p < 0.05). Four patients initially treated with HVI as primary medical treatment was converted to surgical treatment due to an intolerance of HVI or non-healing injuries. Conclusions: The HVI is a safe and effective treatment modality in a subset of patients with complex cervical junction and subaxial cervical spine pathology.