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Objectives The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap.Methods This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R.Results Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves.Conclusion Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity.Level of evidence III.

Objectives Multiple temporary abdominal closure (TAC) techniques are currently used to manage the open abdomen (OA) in severely injured trauma patients, with variability in efficacy and cost. We evaluated the clinical outcomes of two commonly used TAC methods: ABTHERA Negative Pressure Therapy System and whipstitch suture closure (WC).Methods We conducted a retrospective review of patients who had blunt or penetrating trauma from 2015 to 2021 with OA managed using either ABTHERA, WC, or both. Primary outcomes included overall and intensive care unit length of stay, ventilator days, number of laparotomies, time to definitive fascial closure, and complications (bleeding, evisceration, wound dehiscence, and reoperation). Univariate and multivariate analyses were used to compare baseline characteristics, outcomes, and complications. Potential mediators of the relationship between the type of TAC and outcomes were explored using mediation analyses.Results A total of 112 TAC were analyzed; 86 patients had a single type of TAC placement (either WC or ABTHERA), whereas 26 had both types. A majority of patients had blunt trauma in both WC (77%) and ABTHERA (76%) cohorts. There were no differences in baseline characteristics, including injury severity (27.5±12.4 and 27.5±12.0 for ABTHERA and WC, respectively). There was no statistically significant difference among individual complications and overall complications (OR=0.622 (0.274 to 1.412)). No differences were found between the outcomes, and any apparent differences seen were mediated by factors such as a higher number of laparotomies.Conclusion WC is a low-cost option for TAC in trauma, with similar clinical outcomes and complications to ABTHERA.Level of evidence Level III therapeutic/care management study.

Introduction Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI).Methods This was a secondary analysis of a multicenter, case–control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts.Results A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53).Conclusion For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary.Study type Original article, case series.Level of evidence III.

Abstract The USA is currently going through an opioid crisis, associated with tremendous economic and societal impacts. In response to this crisis, healthcare professionals are looking for alternative pain management methods, and non-steroidal anti-inflammatory drugs (NSAIDs) are a sensible choice because of their effectiveness after surgical procedures. However, before surgeons start prescribing NSAIDs in place of opioids, it is crucial to first understand their potential post-surgical complications. The goal of this review is to summarize the data obtained through both animal and human studies, which suggest how a dramatic increase in NSAID use may affect these post-surgical complications. We first provide a short review outlining the mechanisms of action of NSAIDs, followed by a summary of animal studies, which show a trend towards the negative effects of NSAIDs on wound healing and an association between NSAID use and wound infections. Lastly, we present evidence from human studies on the association of NSAIDs with the following complications: anastomotic leaks, necrotizing soft tissue infections, bleeding complications, orthopedic injuries, wound healing, and cancer care. The human studies are much more variable in their conclusions as to whether NSAIDs are beneficial or not, with the only strong evidence showing that NSAIDs inhibit bone healing. This may partially be explained by male and female differences in response to NSAIDs as many animal studies showing the inhibitory effects of NSAIDs were performed on females, while all the human studies were performed with both sexes. We conclude that strong caution should be used in the prescription of NSAIDs, especially in female patients, but larger scale studies are warranted before solid recommendations can be made.

Abstract Background There is increasing evidence that sex differences may influence responses after thermal injury and affect clinical outcomes. The objective of this study was to evaluate the relationships between sex, thermal injury, body size, and inpatient mortality in burn patients. Methods Medical records of adults with >20% total body surface area (TBSA) burn injury admitted to two American Burn Association (ABA)-verified burn centers between 2008 and 2014 were retrospectively reviewed. Injury details and baseline characteristics, including body size as estimated by body surface area (BSA) and body mass index (BMI) were recorded, along with details of the hospital course. The primary outcome of inpatient mortality was compared between sexes. Results Out of 334 subjects, 60 were women (18%). Median TBSA was 33% (IQR 25–49) in this cohort, with 19% full thickness burns and 30% inhalation injury. Despite no significant difference in age, presence of inhalation injury, TBSA, or depth of burn, women had significantly higher rates of inpatient mortality (45 vs. 29%, P = 0.01). BSA was significantly lower in women vs. men (P

Background Trauma care has improved substantially in the last decade. The emphasis of the Golden Hour in trauma care has encouraged the creation of faster transport and earlier prehospital intervention. Despite the clear time-saving advantage helicopter emergency medical services (HEMS) held over ground ambulances (GAs) in the past, advances in prehospital care over the last decade have created uncertainty as to whether HEMS transport is still associated with improved patient outcomes. We aimed to determine whether air transportation was associated with better outcomes compared with ground transportation. We hypothesized that air transportation is associated with better patient outcomes.Methods A retrospective review was performed on the National Trauma Data Bank in 2014 on patients transferred either by helicopter or ground ambulance. Demographic information, mean length of stay, mean ventilator days, and mortality rate was abstracted. All transferred patients and patients with missing information were excluded. χ2 test was performed to analyze categorical variables and independent t-test was performed to analyze continuous variables. A logistic regression was performed to ascertain the effects of Glasgow Coma Scale score, mechanism of injury (blunt vs penetrating), age, gender, Injury Severity Score (ISS), and method of transportation (HEMS vs GA) on the likelihood of mortality.Results A total of 469 407 transferred trauma patients were analyzed. Mortality appeared to be increased in trauma patients transported by helicopter ambulance (6.0%) versus GA (2.9%) (p

ABSTRACT Trauma patients (TPs) are highly susceptible to infections, which often lead to sepsis. Among the numerous causative agents, Pseudomonas aeruginosa is especially important, as P. aeruginosa sepsis is often fatal. Understanding the mechanism of its pathogenesis in bloodstream infections is imperative; however, this mechanism has not been previously described. To examine the effect of trauma-induced changes in blood on the expression of P. aeruginosa genes, we grew strain UCBPP-PA14 (PA14) in blood samples from eight TPs and seven healthy volunteers (HVs). Compared with its growth in blood from HVs, the growth of PA14 in blood from TPs significantly altered the expression of 285 genes. Genes whose expression was significantly increased were related to carbon metabolism, especially malonate utilization and mannitol uptake, and efflux of heavy metals. Genes whose expression was significantly reduced included genes of the type VI secretion system, genes related to uptake and metabolism of amino acids, and genes related to biosynthesis and transport of the siderophores pyoverdine and pyochelin. These results suggest that during systemic infection in trauma patients, and to adapt to the trauma-induced changes in blood, P. aeruginosa adjusts positively and negatively the expression of numerous genes related to carbon metabolism and virulence, respectively. IMPORTANCE While a considerable body of knowledge regarding sepsis in trauma patients is available, the potential influence of trauma-induced changes in the blood of these patients on the pathogenesis of Pseudomonas aeruginosa is basically an unexplored area. Rather than using standard laboratory media, we grew P. aeruginosa in whole blood from either healthy volunteers or trauma patients. The specific changes in the P. aeruginosa transcriptome in response to growth in blood from trauma patients reflect the adaptation of this organism to the bloodstream environment. This knowledge is vital for understanding the strategies this pathogen uses to adapt and survive within the host during systemic infection. Such information will help researchers and clinicians to develop new approaches for treatment of sepsis caused by P. aeruginosa in trauma patients, especially in terms of recognizing the effects of specific therapies (e.g., iron, zinc, or mannitol) on the organism. Further, this information can most likely be extrapolated to all patients with P. aeruginosa septicemia. Author Video: An author video summary of this article is available.

Objective: Alcohol Withdrawal Syndrome (AWS) remains a common problem, especially in trauma and surgical patients. An intravenous ethanol infusion protocol was developed at this institution and previously validated for AWS prophylaxis. One concern with intravenous ethanol has been potential for intoxication and/or side effects. This study was performed on patients receiving AWS prophylaxis with an intravenous ethanol protocol to evaluate for intoxication and the occurrence of any adverse effects. Methods: We did a retrospective review of all patients in our hospital who received AWS prophylaxis by ethanol infusion between 2008 and 2013. Information collected specific to ethanol infusion included rate of administration, serum ethanol levels, serum sodium level, use of benzodiazepines and anti-emetics, and development of AWS. Intoxication was defined using the Texas limit for blood alcohol content in a driver of .08% (80mg/dL). The study period began at admission and lasted 7 days. Results: Ninety-seven patient charts were reviewed. Average serum ethanol level on admission was 137 mg/dL. Serum ethanol levels increased in 12% of patients after administration of ethanol infusion, and levels generally decreased over time. Asymptomatic hyponatremia (serum sodium

A 52-year-old man was admitted to multiple burn facilities five years after an initial work-related chemical burn to his hand, with the claim of a non-healing burn. Further investigation identified characteristics of self-inflicted burn for primary and secondary gain. A literature review of clinically relevant case studies is presented to aid in the identification and diagnosis of suspected factitious illness. Factitious disorders of the hand are frequently under-reported due to variability in presentation, difficulty in detection, and the need for repeat observations necessary for psychological diagnosis. This case serves to highlight key techniques in clinical approach and management for malingering disorders of the upper extremity.

Nutrition has evolved into an integral part of modern critical care for both medical and surgical patients. Multiple international societies now issue evidence-based guidelines to help clinician optimize their patients’ Nutrition. However, adherence to these guidelines throughout the country is poor, and education in nutrition is still lagging in medical school. The authors also highlight four key areas where evidence-based recommendations exist – timing of initiation of enteral feeding, calculating and meeting total daily requirements, use of gastric residual volumes to guide delivery, and interuption of feeding for procedures – but are currently often not followed. Reasons for this lack of adherence are explored, and potential solutions discussed.

Background The ‘Golden Hour’ emphasizes the importance of rapidly providing definitive care to trauma patients. Dispatch time, defined as the time it takes the Helicopter Emergency Medical Service (HEMS) to dispatch from their base and reach the patient, and on-scene time, defined as the time spent with the patient prior to departure to a trauma center, can impact how quickly the patient will reach definitive care. We evaluated HEMS dispatch and on-scene times by investigating the survival rates among patients transported by air to a level 1 trauma center. We hypothesize that longer HEMS dispatch and on-scene times are associated with worse patient outcomes.Methods A retrospective, single institution analysis was performed on patients transported by HEMS. Inclusion criteria were air transported patients aged 18 years and above admitted to a level 1 trauma center from January 1, 2005 to January 1, 2015. Total dispatch time and on-scene times were divided into five incremental groups and mortality data were analyzed. Mortality was defined as death during initial hospital admission. A Pearson’s correlation was used to analyze relationship between dispatch times, on-scene times, and mortality. Simple binary logistic regression was used to run a multivariate analysis on confounding variables of Injury Severity Score (ISS), gender, age, and Glasgow Coma Scale.Results There was a strong positive linear correlation between HEMS on-scene time and mortality, R=0.962, p=0.038. Additionally, there was a positive trend between HEMS dispatch time and mortality. ISS was found to be a significant confounder of mortality in our cohort with on-scene times >20 min, with mortality increasing by 7.5% for every 0.1 increase in ISS score (p=0.01).Conclusion Longer HEMS on-scene and dispatch times appeared to be associated with increased mortality in trauma patients. However, those with higher ISS require longer on-scene times, increasing mortality. Regardless, efforts should focus on reducing on-scene and dispatch times.Level of evidence and study type Level III; Therapeutic/Care Management.

This is a case report of foreign body ingestion in a 55-year-old intellectually disabled man with a history of pica and previous removal of ten plastic gloves from his rectum four months prior to this presentation. The patient presented after ingesting plastic gloves which formed large, rigid esophageal and gastric bezoars that were not amenable to endoscopic removal. An exploratory laparotomy and gastrostomy was performed, and a 10 × 4.5 × 2 cm gastric bezoar consisting of rigid plastic gloves was removed without complication. Special considerations must be taken when considering the ingestion of nonfood items in the intellectually disabled population as these cases may not present classically with symptoms of a gastric bezoar.

Variations in burn perfusion over time as measured by portable ICG fluorescence: A case series

Post-burn skin contractures of the anterior and lateral abdomen and chest may result in respiratory compromise due to limitation of rib excursion. This case report describes a young man with respiratory compromise limiting his daily activity and function, as a result of a 90% burn sustained 6 years previously. Release of his chest and upper abdomen was achieved using “island” scar releases and a cross-linked bovine tendon collagen and glycosaminoglycan and a semi-permeable polysiloxane bilayer matrix dressing (Integra™) followed by subsequent split thickness skin graft. An immediate increase in maximal inspiratory volume was obtained intra-operatively and in the im­mediate post-operative period, and this improvement was sustained after healing of all wounds with subjective relief of the patient’s symptoms.

Objective: To assess the rate and burden of bacterial contamination on unused, nonsterile gloves found in glove boxes in three different specialty intensive care units (ICUs). Design: Descriptive, cross-sectional study Setting: A burn, trauma/surgical, and medical ICU in a 412-bed tertiary care hospital. Subjects: Convenience sample of 90 non-sterile vinyl exam glove pairs Methods: Thirty occupied rooms in each ICU were utilized for collection of glove pair samples. Gloves from opened glove boxes placed in wall-mounted racks for use by healthcare staff were donned by one investigator in a routine, aseptic fashion. The surfaces of both gloves were swabbed, plated onto a contact agar plate and incubated for 48 hours. Resulting colony forming units (CFUs) were counted and recorded for each glove pair sample. Results: Bacterial contaminants were cultured from 73 of 90 (81.1%) glove pairs sampled across all ICUs. Contamination rates of glove samples from the BICU, SICU and MICU were 66.7%, 86.7% and 90.0% respectively. The differences in contamination rate among units was statistically significant (p=0.044). The average contamination burden was 5.83 CFU per glove pair and was not significantly different among units. Conclusions: Despite differences in infection control practices and the composition of pathologies managed in each ICU, the average bioburden of gloves left exposed in the environment was not significantly different. Further research is needed to assess for an association of glove bioburden with nosocomial infection rates and the effects of different infection control practices on the reduction of glove bioburdens.

Background: Necrotizing soft tissue infections (NSTI) are potentially severe infections that have a high morbidity and mortality even with modern medical care. This study examines factors associated with outcomes in patients with NSTI in an academic tertiary care hospital. Design: This is a retrospective cohort study of patients admitted with NSTI between 2003 and 2008. Baseline demographics and comorbid conditions, laboratory and clinical parameters, timing of surgery, and outcomes, including length of stay and mortality, were compared with univariate analysis; significant factors were then analyzed for their effects on mortality using binary logistic regression analysis. Results: Sixty-nine patients with NSTI were analyzed; 61% were men. Diabetes (39%) was the most common comorbid condition. Most infections (55%) were polymicrobial. The most common organism in monomicrobial infections was Staphylococcus aureus, and 50 % of these isolates were methicillin resistant. Nine patients (13%) required amputation. Mortality was 20%, and the most significant predictor of mortality was a higher respiratory rate on admission (p=0.02). Conclusion: Patients in this series frequently had diabetes, usually had polymicrobial infections, and had a 20% mortality rate.

Pseudomonas aeruginosa is a Gram-negative opportunistic pathogen that causes serious infections in immunocompromised hosts including severely burned patients. After multiplying within the burn wound, P. aeruginosa translocate into the bloodstream causing bacterial sepsis frequently leading to organ dysfunction and septic shock. Although the pathogenesis of P. aeruginosa infection of thermally-injured wounds has been extensively analyzed, little is known regarding the ability of P. aeruginosa to adapt and survive within the blood of severely burned patients during systemic infection. To identify such adaptations, transcriptome analyses (RNA-seq) were conducted on P. aeruginosa strain PA14 that was grown in whole blood from a healthy volunteer or three severely burned patients. Compared with growth in blood from healthy volunteers, growth of PA14 in the blood from severely burned patients significantly altered the expression of 2596 genes, with expression of 1060 genes enhanced, while that of 1536 genes was reduced. Genes whose expression was significantly reduced included genes related to quorum sensing, quorum sensing-controlled virulence factors and transport of heme, phosphate, and phosphonate. Genes whose expression was significantly enhanced were related to the type III secretion system, the pyochelin iron-acquisition system, flagellum synthesis, and pyocyanin production. We confirmed changes in expression of many of these genes using qRT-PCR. Although severe burns altered the levels of different blood components in each patient, the growth of PA14 in their blood produced similar changes in the expression of each gene. These results suggest that, in response to changes in the blood of severely burned patients and as part of its survival strategy, P. aeruginosa enhances the expression of certain virulence genes and reduces the expression of others.

A decline in breast cancer incidence has been attributed to the reduction in hormone replacement therapy (HRT) prescriptions since the publication of the landmark WHIT paper in 2003. Concurrently, a relationship between HRT and cerebrovascular disease incidence has also been suggested. No generalized analysis of HRT prescription rates and breast cancer incidence rates that included more than seven years of data. We hypothesized that detailed analysis of SEER data would clarify the relationship between HRT use and breast cancer incidence. Given the large decline in HRT prescription rates uncovered, analyses of potential complications were also conducted, with the understanding that a small effect or one limited to a subpopulation, such as a single race, might not be detected.Incidence rates (per 100,000 women) and standard errors for ductal and lobular breast carcinomas, and endometrioid /endometrial carcinomas in women over 50 years were obtained from the Surveillance, Epidemiology, and End Results (SEER) database 1992-2012. From the Medical Expenditure Panel Survey 1996-2012 weighted counts and standard errors of hormone replacement therapy (HRT) prescriptions for women over 50 years were obtained. Using the National Hospital Discharge Survey (NHDS), 1996-2010 weighted counts and standard errors of femoral neck fractures, total hip replacements, acute myocardial infarctions, and cerebral infarctions were obtained for 50+ year men and women. Weighted counts and standard errors were divided by US census figures and multiplied by 100,000. Joinpoint regression was used to analyze rates.Beginning 2001, HRT prescription rates dropped dramatically, 2001-2012 AAPC -14.9 (95% CI -17.4, -12.4). Breast cancer rates, which began to decline in 1999, increased after 2003; 2012 rates were similar to those seen in 2001 for both ductal, AAPC 0.1 (-0.4, 0.6) and lobular, AAPC 0.5 (-0.4, 1.5), carcinoma. Endometrial carcinoma rates increased, 2001-2012 AAPC 3.5 (3.1, 3.8), arguing against a negative effect of HRT discontinuation of endometrial carcinoma. Tests for parallelism failed to detect APC differences among genders for femoral neck fractures (P = 0.24), for total hip replacements (P = 0.11), for myocardial infarctions (P = 0.10), or for cerebral infarctions (P = 0.19), precluding any assignment of general effect on these disorders by HRT.Using SEER data, we demonstrated that changes in breast cancer rates cannot be explained by HRT prescription rate changes.

Background: Smoke inhalation is a major source of morbidity and mortality. Heparin and N-acetylcysteine treatment has potential efficacy in inhalation injury. We investigated the impact of a heparin/N-acetylcysteine/albuterol nebulization protocol in adult patients with inhalation injury. Methods: A retrospective review was performed of adult inhalation injury patients, admitted to a regional burn center between January 2011 and July 2012, who underwent a protocol of alternating treatments of heparin and N-acetylcysteine/albuterol nebulization every 4 hours. The study cohort was matched 1:1 by age, sex, and burn size to a control cohort admitted within 5 years before protocol implementation. Results: The study (n = 20) and control cohorts (n = 20) were well matched, with nearly identical age (50 vs 49 years), sex distribution (70% male), burn size (total body surface area, 22% vs 21%), and inhalation injury, except grade I injuries (79% vs 47%, P = 0.01). The protocol did not change mortality (30% vs 25%, P = 0.72) or duration of mechanical ventilation (8.5 vs 8.8 days, P = 0.9). There was no difference in development of sepsis (40% vs 33%, P = 0.7) or acute respiratory distress syndrome (15% vs 10%, P = 1); however, those who received the protocol were more likely to develop pneumonia (45% vs 11%, P = 0.03). Conclusions: The implementation of a heparin/N-acetylcysteine/albuterol protocol did not reduce mortality or duration of mechanical ventilation in this cohort of adults with inhalation injury and resulted in a significant increase in pneumonia rates. Larger prospective studies are necessary, with close attention paid to minimizing the infection risk incurred from frequent administration of nebulized medications.

Diabetes mellitus (DM) affects 23.6 million people in the USA and approximately 20–25% of diabetic patients will develop foot ulceration during the course of their disease. Up to a quarter of these patients will develop infections that will necessitate amputation. Although many studies report that the rates of antibiotic resistant infections have increased dramatically in the DM population over the last decade, to our knowledge there have been no reports directly comparing the rates of antibiotic resistant infections in DM versus non-DM wounds. We performed a retrospective study comparing the wound infections of 41 DM patients to those of 74 non-DM patients to test the hypothesis that infections with multidrug resistant organisms (MDRO) were more prevalent in the DM population. We found that 63.4% of DM and 50% of non-DM patients had MDRO infections, which was not statistically different. However, 61% of the DM patients had Pseudomonas infections compared to only 18.9% of non-DM patients. Furthermore, DM patients had significantly more coinfections with both Pseudomonas and Staphylococcus aureus. Though our initial hypothesis was incorrect, we demonstrated a significant correlation between Pseudomonas and Pseudomonas/S. aureus coinfections within DM wounds.

This image showed the picture of a very heavy woman who initially had an NSTI of the right leg which was extensively debrided and skin grafted and healed well, then presented 2 months later with a new NSTI of the left leg.