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Background Pediatric pelvic fractures are a significant source of morbidity for children in the United States. In the era of specialized care, the relationship between trauma center designation and outcomes remains unknown. We hypothesized that there would be no difference in patient outcomes when treated at adult trauma centers (ATCs), pediatric trauma centers (PTCs), or dual trauma centers (DTCs). Materials and methods We used the National Trauma Data Bank to identify pediatric (≤14 y) patients suffering pelvic fractures in 2013-2015. DTCs were defined as centers with level I or II trauma designation for both pediatric and adult care. Primary outcomes included mortality, complications, and computed tomography (CT) utilization. Results There were 4260 patients who met study criteria. Of these, 1290 (22%) were treated at ATCs, 1332 (30%) at PTCs, and 2120 (48%) at DTCs. Pediatric patients treated at ATCs were more likely to suffer a complication or receive a CT scan. On multivariate analysis, patients treated at PTCs and DTCs were significantly less likely to have a recorded complication or receive head, thoracic, or whole-body CT scans compared with ATCs. DTCs, but not PTCs, used fewer abdominal CT scans. Mortality rates were not predicted by center designation. Conclusions For pediatric pelvic fractures, centers with pediatric trauma designation (PTCs and DTCs) appear to have better outcomes despite significantly less use of CT scans. Further studies are needed to determine optimal management of pediatric pelvic fractures while minimizing exposure to ionizing radiation. Level of evidence Level III Retrospective.

Familial partial lipodystrophy (FPLD) is a rare and heterogenous disease without gold-standard diagnostic criteria. The heterogeneity applies to fat distribution, symptomatology, metabolic complications, and genetic etiology. Disease heterogeneity has contributed to the lack of standardized diagnostic criteria, an obstacle to understanding both the natural history of the disease and response to therapies. We have assessed whether DXA data can aid in disease diagnosis. DXA scans quantify fat and lean mass in the whole body, arms, legs, and trunk. An increased ratio of fat percentage in the trunk to the legs (termed "trunk-leg ratio", TLR) has been proposed as an objective method to detect FPLD. Using large sets of DXA data from control subjects, along with data from FPLD subjects, we sought to improve upon TLR. We hypothesized that TLR might change as a function of overall adiposity (total body fat, TF). Females were studied first because of the high female: male ratio of disease prevalence observed in FPLD. In 2713 control females with DXA measurements within the UKBiobank (UKB), TLR increased linearly as a function of TF until a TF of ∼36% and then the TLR plateaued with higher TF. We analyzed published DXA data of FPLD subjects from the USA (n=55).1 FPLD subjects had higher TLRs than controls at each level of adiposity. Due to the non-linear relationship between total adiposity and TLR, two linear fits were generated to best discriminate controls from FPLD subjects for a given adiposity. For females with body fat TF*0.0311+0.232. For females with body fat ≥36%, the algorithm predicts FPLD if TLR >1.353. After training on this UKB data set, we tested the algorithm on independent data sets of control females from NHANES (n=2347) and FPLD subjects (n=37, from the NIH). The algorithm had a sensitivity of 92–97% and a specificity of 99.3%. This degree of specificity is still not sufficient for implementation of rare disease screening in the general population, but could be useful in a population with increased pre-test probability of having FPLD such as non-obese individuals with Type 2 diabetes and/or hypertriglyceridemia. Because race and ethnicity are possible modifiers of body fat distribution, we examined the relationship between TF and TLR across ethnic and racial groups in NHANES. Mexican-Americans (n=659), Hispanic-other (n=81), White (n=871), Black (n=612), and other/biracial (n=124) subjects from NHANES had a similar relationship between adiposity and TLR. Therefore, the same DXA criteria can be applied across these ethnicities. In summary, the relationship between adiposity and TLR may be used to aid in the diagnosis of FPLD in females. Reference Meral R, et al. Diabetes Care. 2018;41,2255–2258. Presentation: Saturday, June 11, 2022 1:06 p.m. - 1:11 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

The association of procedure volume and improved outcomes has been established with infrequently performed elective operations. However, effect of trauma center volume on outcomes in emergency surgery has not been defined. We hypothesized that high volume centers (HVC) would provide better outcomes for operative major vascular injuries (MVI) than low volume centers (LVC).The NTDB was queried from 2010 to 2014. Patients with MVI were identified and HVC were compared to LVC. HVC were defined as480 patients per year with ISS≥15.There were 37,125 patients with MVI, with 16,461 (44.3%) managed operatively. Of these, 15,965 (97%) underwent surgery at HVC and 496 (3%) at LVC. There was no difference in shunt utilization, however, HVC were more likely to utilize endovascular repair (31.0% vs. 21.9%, p 0.001). Rates of death, amputation, and compartment syndrome were similar. HVC were more likely to develop pneumonia or sepsis. On logistic regression, HVC was not associated with survival (OR: 0.90, 95%CI: 0.60-1.34, p = 0.60). Variables associated with mortality for HVC and LVC included thoracic arterial injury (OR: 1.57, 95%CI: 1.27-1.94, p 0.001), penetrating mechanism (OR:1.84, 95%CI: 1.57-2.15, p 0.001), and open repair (OR: 1.95, 95%CI: 1.69-2.26, p 0.001). Lower ISS (OR: 0.29, 95%CI: 0.24-0.34, p 0.001) and higher presenting blood pressure (OR: 0.99, 95%CI: 0.99-1.00, p 0.001) were associated with survival.Although LVC may have less proficiency with endovascular techniques, trauma center volume does not influence survival in emergency surgery for MVI.

Background Penetrating neck trauma continues to present a diagnostic dilemma. Practice guidelines advocate the use of computed tomography angiography (CTA) for suspected vascular or aero-digestive injuries in all neck zones. There is also an evolving evidence of 'No Zone' approach where the decision to obtain a CTA is guided by physical exam findings and clinical presentation. The aim of this systematic review is to examine existing literature on the diagnostic accuracy of CTA as an integral component of the "no zone" approach in stable patients witt penetrating neck trauma. Methods We performed a systematic review using an electronic search of three databases (PubMed, Medline, Cochrane Review) from 2000-2017. Results A total of 5 prospective and 8 retrospective studies were included. The sensitivity of CTA ranged from 83-100%; specificity, 61-100%; positive predictive value, 30-100% and negative predictive value, 90-100%. Three studies reported high sensitivity and specificity for the detection of vascular injuries, but low specificity for aero-digestive tract injuries. When stratified by clinical presentation, CTA had a sensitivity of 89.5-100% and specificity of 61-100% in stable patients presenting with soft signs. In a combined group of stable patients with either hard signs or soft signs, the sensitivity of CTA was 94.4-100% and specificity 96.7-100%. Among patients presenting with hard signs, the sensitivity of CTA was 78.6-90% and specificity is 100%. Conclusions This is the first systematic review to examine the role of computed tomography angiography in penetrating neck trauma. In combination with physical exam, CTA demonstrated a reliable high sensitivity and specificity for detecting injuries in penetrating neck trauma in stable patients with soft signs of injury and select patients with hard signs of injury. These results support the management of penetrating neck trauma using "no zone" approach based on physical examination and the use of CTA in stable patients. Level of evidence Systematic Review, level IV.

First bite syndrome (FBS) is a sharp unilateral pain in the vicinity of the angle of the mandible after taking the first bite of a meal that presents typically after surgery in the area of the ipsilateral parapharyngeal space. It is not confirmed what the pathophysiology is that causes this pain, but the proposed mechanism is the iatrogenic damage of sympathetic fibers that extend from the superior cervical ganglion (SCG) to innervate the parotid gland. The presentation of this syndrome has been acknowledged in patients who have undergone head and neck tumor resections, but it has not been documented in the same thorough manner among vascular surgery cases in the parapharyngeal space, possibly because of a higher risk of development in other head and neck surgeries, or to under-reporting of cases. To date, only 5 cases of FBS status post carotid endarterectomy have been documented in the literature. Definitive treatment of FBS has not been established. Some studies have shown improvement with amitriptyline, and carbamazepine as well as botulinum toxin injections. We will present the case of a 75 year old male who developed first bite syndrome after a right carotid endarterectomy with efforts of raising awareness of a potential acute complication of carotid endarterectomy.

Trauma patients receiving massive transfusion protocol (MTP) are at risk of citrate-induced hypocalcemia and hyperkalemia. Here we evaluate potassium (K), ionized calcium (iCa), and K/iCa ratio as predictors of mortality.This retrospective study includes all adult trauma patients who received MTP within 1 h at our level I trauma center between 2014 and 2019. Receiver operating characteristic curve analysis assessed predictive accuracy of K/iCa ratio at admission on 120-day mortality.Of 614 patients, 146 received MTP within 1 h and 38 expired. Patients who expired had higher K/iCa ratio than survivors (median [IQR] = 5.7 [3.8-7.2] vs 3.7 [3.1-4.9], p 0.001). Area under the curve of K/iCa was 0.72 (95%CI = 0.62-0.82, p 0.001) with sensitivity = 63.2% and specificity = 77.6%. At the optimum K/iCa cutoff (5.07), patients with high ratios had 4 times higher mortality risk (HR = 3.97, 95%CI = 1.89-8.32, p 0.001).Elevated K/iCa ratio was an independent predictor of mortality in trauma patients managed with MTP.

Massive transfusion (MT) is a lifesaving treatment for hemorrhaging patients. Predicting the need for MT is crucial to improve survival. The aim of our study was to validate the Revised Assessment of Bleeding and Transfusion (RABT) score to predict MT in a multicenter cohort of trauma patients. We performed a (2015–2017) analysis of adult (age ≥ 18 year) trauma patients who had a high-level trauma team activation at three Level I trauma centers. The RABT was calculated using the 4-point score [blunt (0)/penetrating trauma (1), shock index ≥ 1 (1), pelvic fracture (1), and FAST positive (1)]. A RABT score of ≥ 2 was used to predict MT (≥ 10 units of packed red blood cells within 24 h). The area under the receiver operating characteristic curve (AUROC) was calculated to assess the score’s predictive power compared to the Assessment of Blood Consumption (ABC) score. We analyzed 1018 patients: 216 (facility I), 363 (facility II), and 439 (facility III). The mean age was 41 ± 19 year, and the injury severity score (ISS) was 29 [22–36]. The overall MT rate was 19%. The overall AUROC of RABT ≥ 2 was 0.89. The sensitivity of the RABT ≥ 2 was 78%, and the specificity was 91%. The RABT score had a higher sensitivity (78% vs. 69%) and specificity (91% vs. 82%) than the ABC score. The RABT score is a valid tool to predict MT in severely injured trauma patients. It is an objective score that aids clinicians in predicting the need for MT to mobilize blood products and minimize the waste of resources.