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We analyzed the impact of treating center designation and case volume of penetrating trauma on outcomes after pediatric penetrating thoracic injuries (PTI).PTI patients18 years were identified from the National Trauma Data Bank (2013-2016). Centers were categorized by type (Pediatric or Adult) and designation status (Level I, Level II, and other). Performance was calculated as the difference between observed and expected mortality and standardized using the total penetrating trauma volume per center. Expected mortality was calculated using the Trauma Mortality Prediction Model. Pearson correlation and linear mixed-effects models evaluated the association between variables and performance.We identified 4,134 PTI patients treated at 596 trauma centers: 879 (21%) at Adult Level I, 608 (15%) at Adult Level II, 531 (13%) at Pediatric Level I, 320 (8%) at Pediatric Level II, and 1,796 (43%) at other centers. Primary injury mechanisms were firearm-related (58%) and cut/piercing (42%). Overall mortality was 16% and median predicted mortality was 3.6% (IQR: 1.5% - 11.2%). Among patients with thoracic firearm-related injuries, centers with lower penetrating case volume and total trauma care demonstrated significantly worse outcomes. Multivariable analysis revealed Adult Level I centers had superior outcomes compared with all other non-Level I centers. There was no difference in mortality between Pediatric and Adult Level I centers.Adult Level I trauma center designation and annual case volume of penetrating thoracic trauma are associated with improved mortality after pediatric firearm-related thoracic injuries. Further study is needed to identify factors in higher volume centers that improve outcomes.Level III.

Background Trauma patients are resource intensive, requiring a variety of medical and procedural interventions during hospitalization. These expenses often label trauma care as “high cost” based on gross hospital charges. We hypothesized that a financial metric built on actual costs and clinically relevant trauma patient cohorts would demonstrate a lower true cost of trauma care than the standardly reported gross hospital charges. Methods We examined all trauma patients (≥16 yr) treated in 2017 from a single institution and matched them to the institution’s detailed financial accounting data. The organization’s Financial Operations Division is uniquely able to allocate total operating costs across patient encounters to include medications, procedures, and salaries/fees from medical professionals and administrators. Patient subgroups were identified by Trauma Quality Improvement Program (TQIP) criteria for cost comparisons. Results Overall median cost per patient was $6,544 [IQR $4,975-14,532] for 2,548 patients. The median cost per patient increased with Injury Severity Score (ISS) ranging from $5,457(ISS ≤ 7) to $34,898(ISS ≥ 21), each accompanied by an average 548% increase in gross charges. Costs also varied widely from $13,498 [IQR $8,247–26,254] to $45,759 [IQR $22,186-113,993] across TQIP patient cohorts. Of the total cost, 91% was attributed to personnel alone. Discussion Measuring the true cost of trauma care is feasible. As hypothesized, the true cost of trauma care is lower than charges. True cost increased with injury severity with variable cost across subgroups. Non-physician staff and administration are the largest component of the cost of trauma care.

Background We investigated the potential link between trauma center American College of Surgeons verification level and institutional volume of penetrating thoracic trauma with outcomes for patients with penetrating thoracic trauma. Methods Penetrating thoracic injuries were identified in the National Trauma Data Bank from 2013 to 2016. Primary exposures were trauma center American College of Surgeons verification level and annual penetrating trauma caseload by center. Cox models were used to evaluate the association between primary exposures and mortality. Poisson regression was used to evaluate admission and outcome rate differences by trauma center status. Results Of 68,727 patients identified, 38% were treated at level I centers, 18% at level II centers, and 44% at other centers. Only 3.1% required major surgery for thoracic injury (3.1% at level I, 2.6% at level II, and 3.2% at other). Overall, annual volume of penetrating thoracic trauma was not associated with mortality. For specific injuries, level I centers had superior outcomes for injuries to the thoracic aorta and vena cava compared with other centers. Level I centers also showed improved outcomes for lung/bronchus injuries compared with level II centers. Level I centers had less sepsis/acute respiratory distress syndrome, but more surgical site infection, venous thromboembolism, and unplanned operation compared with non–level I centers. Conclusions There was no identified impact of penetrating thoracic trauma volume or trauma center verification level on overall mortality. However, level I verification did correlate with improved outcomes for some specific injuries. Further study to identify factors that improve outcomes in patients with high-risk penetrating thoracic mechanisms is warranted.

BACKGROUND Low-molecular-weight heparin (LMWH) is widely used for venous thromboembolism chemoprophylaxis following injury. However, unfractionated heparin (UFH) is a less expensive option. We compared LMWH and UFH for prevention of posttraumatic deep venous thrombosis (DVT) and pulmonary embolism (PE). METHODS Trauma patients 15 years or older with at least one administration of venous thromboembolism chemoprophylaxis at two level I trauma centers with similar DVT-screening protocols were identified. Center 1 administered UFH every 8 hours for chemoprophylaxis, and center 2 used twice-daily antifactor Xa-adjusted LMWH. Clinical characteristics and primary chemoprophylaxis agent were evaluated in a two-level logistic regression model. Primary outcome was incidence of DVT and PE. RESULTS There were 3,654 patients: 1,155 at center 1 and 2,499 at center 2. The unadjusted DVT rate at center 1 was lower than at center 2 (3.5% vs. 5.0%; p = 0.04); PE rates did not significantly differ (0.4% vs. 0.6%; p = 0.64). Patients at center 2 were older (mean, 50.3 vs. 47.3 years; p < 0.001) and had higher Injury Severity Scores (median, 10 vs. 9; p < 0.001), longer stays in the hospital (mean, 9.4 vs. 7.0 days; p < 0.001) and intensive care unit (mean, 3.0 vs. 1.3 days; p < 0.001), and a higher mortality rate (1.6% vs. 0.6%, p = 0.02) than patients at center 1. Center 1's patients received their first dose of chemoprophylaxis earlier than patients at center 2 (median, 1.0 vs. 1.7 days; p < 0.001). After risk adjustment and accounting for center effects, primary chemoprophylaxis agent was not associated with risk of DVT (odds ratio, 1.01; 95% confidence interval, 0.69-1.48; p = 0.949). Cost calculations showed that UFH was less expensive than LMWH. CONCLUSION Primary utilization of UFH is not inferior to LMWH for posttraumatic DVT chemoprophylaxis and rates of PE are similar. Given that UFH is lower in cost, the choice of this chemoprophylaxis agent may have major economic implications. LEVEL OF EVIDENCE Prognostic and epidemiological, level II; Therapeutic, level III.

Background Extremity vascular injuries in children are rare events that present unique therapeutic challenges. The absence of a pediatric-specific protocol for definitive care of these injuries risks variability in treatment practices and outcomes. Using a nationwide data set, we investigated variations in the management and outcomes of pediatric patients with peripheral vascular trauma and characterized differences based on hospital category. Methods Retrospective cohort study using the American College of Surgeons (ACS) National Trauma Data Bank to identify patients 16 years or younger with extremity vascular trauma admitted in calendar year 2016. Hospitals were categorized as ACS-verified pediatric trauma centers (Level I or II), ACS-verified adult trauma centers (Level I or II), or other hospitals (all other trauma centers and nondesignated hospitals). Patient data were evaluated by hospital category. Results Among 164,882 pediatric admissions, 702 patients were identified for analysis. There were 430 (61.3%) patients with upper-extremity injuries, 270 (38.5%) with lower-extremity injuries, and 2 (0.2%) had both. Mean age was 11.5 years, and 51.6% were blunt-injured. Overall, 40.2% were admitted to pediatric trauma centers, 28.9% to adult trauma centers, and 30.9% to other hospitals. Hospitals without ACS trauma center verification had a significantly higher amputation rate than any ACS-verified adult or pediatric center (p = 0.013). Conclusion The incidence of pediatric extremity vascular injury is low. Hospitals with ACS trauma center verification have greater pediatric limb salvage rates than those without verification. Future study should seek to identify specific regional or resource-related factors that contribute to this disparity. Level of evidence Epidemiological, level III.

IntroductionSince their release in 2017, standing electric motorized scooters (eScooters) have risen in popularity as an alternative mode of transportation. We sought to examine the incidence of injury, injury patterns, prevalence of helmet and drug and alcohol use in eScooter trauma.MethodsThis was a multi-institutional retrospective case series of patients admitted for injuries related to operation of an eScooter following the widespread release of these devices in September 2017 (September 1, 2017 to October 31, 2018). Demographics, drug and alcohol use, helmet use, admission vitals, injuries, procedures, hospital and intensive care unit length of stay (LOS), death, and disposition were analyzed.Results103 patients were admitted during the study period, and monthly admissions increased significantly over time. Patients were young men (mean age 37.1 years; 65% male), 98% were not wearing a helmet. Median LOS was 1 day (IQR 1–3). 79% of patients were tested for alcohol and 48% had a blood alcohol level >80 mg/dL. 60% of patients had a urine toxicology screen, of which 52% were positive. Extremity fractures were the most frequent injury (42%), followed by facial fractures (26%) and intracranial hemorrhage (18%). Median Injury Severity Score was 5.5 (IQR 5–9). One-third of patients (n=34) required an operative intervention, the majority of which were open fixations of extremity and facial fractures. No patients died during the study. The majority of patients were discharged home (86%).ConclusioneScooter-related trauma has significantly increased over time. Alcohol and illicit substance use among these patients was common, and helmet use was extremely rare. Significant injuries including intracranial hemorrhage and fractures requiring operative intervention were present in over half (51%) of patients. Interventions aimed at increasing helmet use and discouraging eScooter operation while intoxicated are necessary to reduce the burden of eScooter-related trauma.Level of evidenceLevel IV.

The ability of an antimicrobial, cationic polyethylenimine (PEI+) to induce the three known extracytoplasmic stress responses of Escherichia coli was quantified. Exposure of E. coli to PEI+ in solution revealed specific, concentration-dependent induction of the Cpx extracytoplasmic cellular stress response, ~2.0-2.5 fold at 320 μg/mL after 1.5 hours without significant induction of the σE or Bae stress responses. In comparison, exposure of E. coli to a non-antimicrobial polymer, polyethylene oxide (PEO), resulted in no induction of the three stress responses. The antimicrobial small molecule vanillin, a known membrane pore-forming compound, was observed to cause specific, concentration-dependent induction of the σE stress response, ~6-fold at 640 μg/mL after 1.5 hours, without significant induction of the Cpx or Bae stress responses. The different stress response induction profiles of PEI+ and vanillin suggest that although both are antimicrobial compounds, they interact with the bacterial membrane and extracytoplasmic area by unique mechanisms. EPR studies of liposomes containing spin-labeled lipids exposed to PEI+, vanillin, and PEO reveal that PEI+ and PEO increased membrane stability whereas vanillin was found to have no effect.

Characterizing chemical changes within individual cells is important for determining fundamental mechanisms of biological processes that will lead to new biological insights and improved disease understanding. Analyzing biological systems with imaging and profiling mass spectrometry (MS) has gained popularity in recent years as a method for creating chemical maps of biological samples. To obtain mass spectra that provide relevant molecular information about individual cells, samples must be prepared so that salts and other cell culture components are removed from the cell surface and that the cell contents are rendered accessible to the desorption beam. We have designed a cellular preparation protocol for imaging/profiling MS that removes the majority of the interfering species derived from the cellular growth medium, preserves the basic morphology of the cells, and allows chemical profiling of the diffusible elements of the cytosol. Using this method, we are able to reproducibly analyze cells from three diverse cell types: MCF7 human breast cancer cells, Madin-Darby canine kidney (MDCK) cells, and NIH/3T3 mouse fibroblasts. This preparation technique makes possible routine imaging/profiling MS analysis of individual cultured cells, allowing for understanding of molecular processes within individual cells.