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Background Perforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks. Methods We conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not. Results Our analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%–87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000). Conclusion Routine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.

The American Board of Surgery In-Training Examination (ABSITE) is an annual exam taken by general surgery residents as a cognitive assessment of the knowledge gained throughout each year of training. Several question banks are available for ABSITE preparation. However, ABSITE Quest (AQ) utilizes a method called spaced education which has been demonstrated to help with retaining information longer and improve exam performance. This study hypothesizes that using this method will help residents improve their ABSITE performance.Retrospective survey data was collected from residents who participated in AQ, including postgraduate year (PGY) level, as well as 2019 and 2020 ABSITE percentiles. AQ user data was used to match respondent's total number of questions completed and daily engagement level to the survey data. Paired, single-tailed student's t test was used to evaluate the significance of ABSITE percentile change between 2019 and 2020 among AQ users.ChristianaCare, Newark, DE, United States. Nonclinical.All ABSITE Quest users were surveyed (n = 390), of which 104 responded. 21 responses were from PGY1 residents and were excluded, resulting in a total of 83 responses.The mean percentile difference of AQ users from 2019 to 2020 was +15.8 (p0.00001). When categorizing by the total number of questions completed, high users demonstrated a mean percentile difference of +15.3 (p = 0.00002), average users had a difference of +19.1 (p = 0.00029), and low users showed a percentile difference of +1.2 (p = 0.45244). When categorizing by daily engagement level, high users demonstrated a mean percentile difference of +17.9 (p0.00001), low users had a mean percentile difference of +15.3 (p = 0.00124), and minimal users showed a mean percentile change of -5.7.The use of the spaced education method with ABSITE Quest, especially in users with a greater number of questions completed and high levels of daily engagement, correlated with a significant improvement on ABSITE performance.

To determine if there is a significant association between administration of tranexamic acid (TXA) in severely bleeding, injured patients, and venous thromboembolism (VTE), myocardial infarction (MI), or cerebrovascular accident (CVA). A multicenter, retrospective study was performed. Inclusion criteria were: age 18-80 years old and need for 5 units or more of blood in the first 24 h after injury. Exclusion criteria included: death within 24 h, pregnancy, administration of TXA more than 3 h following injury, and routine ultrasound surveillance for deep venous thrombosis. Incidence of VTE was the primary outcome. Secondary outcomes included MI, CVA, and death. A power analysis found that a total of 830 patients were needed to detect a true difference in VTE risk. 1333 patients (TXA = 887, No-TXA = 446 patients) from 17 centers were enrolled. There were no differences in age, shock index, Glasgow coma score, pelvis/extremity abbreviated injury score, or paralysis. Injury severity score was higher in the No-TXA group. Incidence of VTE, MI, or CVA was similar between the groups. The TXA group required significantly less transfusion (P < 0.001 for all products) and had a lower mortality [adjusted odds ratio 0.67 (95% confidence interval 0.45-0.98)]. Despite having a higher extremity/pelvis abbreviated injury score, results did not change when evaluating only patients with blunt injury. Use of TXA in bleeding, injured patients is not associated with VTE, MI, or CVA but is associated with a lower transfusion need and mortality.

The incidence of patients with trauma on novel oral anticoagulants (NOACs) for the treatment of thromboembolic disorders is increasing. In severe bleeding or hemorrhage into critical spaces, urgent reversal of this underlying pharmacologic coagulopathy becomes paramount. Optimal reversal strategy for commonly used NOACs is still evolving. Basic tenets of evaluation of patients with trauma and resuscitation remain the same. Clinical outcomes data in bleeding human patients with trauma are lacking, but are needed to establish efficacy and safety in these treatments. This article summarizes the available evidence and provides the optimal reversal strategy for bleeding patients with trauma on NOACs.

IntroductionGunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR.MethodsWe performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation.Results825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation.ConclusionWe found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition.Level of evidenceLevel II.

Trauma patients pose unique challenges when it comes to the decision for optimal thromboprophylaxis. Risk reduction of venous thromboembolic (VTE) events is paramount in the modern management of trauma patients. The choice of pharmacologic prophylaxis is standard for most hospitalized patients. However, the potential for bleeding complications with this therapy, in a subset of major trauma patients, can have dire consequences. Fortunately today, a variety of mechanical compression methods exist to assist in the optimal management of VTE prophylaxis for trauma patients. Graduated compression stockings, pneumatic compression devices, foot pumps, and neuromuscular electrical stimulators are just a few of the choices in today’s providers’ armamentarium. In this review, we discuss the need for mechanical VTE prophylaxis in trauma patients, the mechanisms of clot prevention associated with the available devices, and take an evidence-based look at the efficacy of the mechanical methods available for VTE prophylaxis.

Dirnberger, J. M. and J. Weinberger. 2005. Influences of lake level changes on reservoir water clarity in Allatoona Lake, Georgia. Lake and Reserv. Manage. Vol. 21(1):24-29. In Allatoona Lake (Georgia USA), secchi transparency (measured every 2 to 4 weeks during a Phase I U.S. EPA Clean Lakes Study) was typically 5- to 8- fold greater in summer than late autumn and winter. The intensity of storms increased in late autumn and winter resulting in high sediment loads from the watershed, but lake level was also drawn down, confounding the influence of external sediment load with that of resuspended lake sediments. For 4 of the 5 years studied, decreases in water clarity were more closely synchronized with lowering of lake level than with storms. Continuous automated sampling of turbidity and other water quality parameters at 15-minute intervals allowed us to assess whether turbidity increases were derived from erosion of the exposed shoreline (i.e., by rain and runoff), or wave-driven resuspension. Regular increases in turbidity and decreases in pH occurred each weekend during the summer, suggesting increased mixing by boat traffic. Increases in turbidity on weekends and after rain events were greater after initiation of drawdown and were particularly strong when lake surface elevation approached that of the summer metalimnion depth. It appears that sediment focused (deposited) in deeper areas during the spring and summer is resuspended by wave action as lake levels drop in autumn.