Search

Background The role of advanced registered nurse practitioners and physician assistants in emergency departments, trauma centers, and critical care is becoming more widely accepted. These personnel, collectively known as advanced practice providers, expand physicians' capabilities and are being increasingly recruited to provide care and perform invasive procedures that were previously performed exclusively by physicians. Objectives To determine whether the quality of tube thoracostomies performed by advanced practice providers is comparable to that performed by trauma surgeons and to ascertain whether the complication rates attributable to tube thoracostomies differ on the basis of who performed the procedure. Methods Retrospective blinded reviews of patients' charts and radiographs were conducted to determine differences in quality indicators, complications, and outcomes of tube thoracostomies by practitioner type: trauma surgeons vs advanced practice providers. Results Differences between practitioner type in insertion complications, complications requiring additional interventions, hospital length of stay, and morbidity were not significant. The only significant difference was a complication related to placement of the tube: when the tube extended caudad, toward the feet, from the insertion site. Interrater reliability ranged from good to very good. Conclusions Use of advanced practice providers provides consistent and quality tube thoracostomies. Employment of these practitioners may be a safe and reasonable solution for staffing trauma centers. [ABSTRACT FROM AUTHOR]

Objectives: Acute Care Surgery (ACS) admissions and procedures are substantially increasing. ACS disproportionally accounts for a majority of morbidity and mortality among surgical patients. Minimally invasive techniques are associated with improved outcomes and shorter hospital length of stay within the ACS population. While laparoscopy is widespread, ACS surgeons have been slower to adopt the use of robotics. We aimed to evaluate the feasibility of incorporating robotic surgery within ACS practice., Methods: Robotic General Surgery operations performed by 8 Acute Care Surgeons from 5 local facilities within a large integrated healthcare system were queried over a 15 month period. Patients who underwent emergent, urgent, sub-acute, and elective robotic operations by ACS staff were identified. Demographics collected included age, gender, BMI, and ASA score. Outcomes recorded included procedure classification, total supply and implant charges (TSI), conversion to open, hospital length of stay (LOS), 30 day readmission, and 30 day mortality., Results: Of 200 operations, the most common were Cholecystectomy (43.5%), Inguinal hernia repair (26.0%), Ventral hernia repair (18.0%), Appendectomy (5.0%), and Sigmoid Colectomy (3.5%). The median (± std dev) age was 48 ± 16.66 years and BMI was 29.9 ± 8.79 kg/m 2 . 46% of cases were sub-acute (n = 92), 33.5% were elective (n = 67), 14% were emergent (n = 28), and 6.5% were urgent (n = 13). Most patients were ASA 2 (107, 46.1%) or ASA 3 (71, 45.9%). The median (IQR) TSI and LOS were $1,770 (889.50) USD and 0.1 (0.9) days. Forty-one inpatient procedures were performed. Median LOS was 3 days and expected LOS was 3.1 days (O:E = 0.96). Five patients were readmitted within 30 days, and there were no deaths within 30 days., Conclusion: Robotic techniques may be safely implemented by ACS surgeons, potentially benefitting both patient and surgeon. LOS was similar between laparoscopic and robotic cases and only two cases required conversion to an open procedure. Next steps include a multi-center prospective trial comparing robotic to laparoscopic cases., Competing Interests: Declarations. Disclosures: V. Christian Sanderfer MD, Stephanie Jensen MD MPH, Hisham I. Qadri BS, Hongmei Yang Ph.D, Emily C. Benham MD, Cynthia Lauer MD, Kathryn Muir, MD, Michael S. Clemens MD, Sean R. Maloney MD, William C. Sherrill MD, Addison K. May MD MBA, and Samuel W. Ross MD MPH do not have any conflicts of interest or financial ties to disclose. Bradley W. Thomas MD is a consultant for Zimmer Biomet., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The traditional treatment of traumatic hemothorax (HTX) is large bore chest tubes (CT) ≥28Fr. Recent evidence shows 14Fr pigtail catheters are as effective in drainage of HTX as larger CT. However, this has not been shown in 14Fr Thal tubes, a straight chest tube placed utilizing Seldinger technique., Methods: A single center, prospective randomized controlled trial was performed at an ACS verified Level 1 trauma center comparing 14Fr Thal CT (14CT) to 28Fr CT (28CT) between May 2017 and September 2021. The primary outcome was failure of drainage of hemothorax requiring additional intervention. Secondary outcomes included duration of chest tube placement, length of stay, tube-specific complications, and 90-day hospital readmission. Farrington-Manning approach was used for non-inferiority tests. Wilcoxon 2-samples test or t test was used for continuous variables, and Pearson chi-square or Fisher exact test was used for categorical variables., Results: 109 patients were included in the randomized trial. There were 54 patients in the 14CT cohort, and 55 patients in the 28CT cohort. The primary outcome of drainage failure was similar between groups (8.3% 14CT vs 3.9% 28CT). Using a 15% non-inferiority margin 14CT is non-inferior to 28CT. No differences were identified in secondary outcomes., Conclusion: 14Fr Thal tubes have similar efficacy in drainage of traumatic hemothorax when compared with 28Fr chest tubes with similar complication rates (NCT03167723)., 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: Emergency General Surgery (EGS) represent a wide spectrum of diseases with high complication and mortality rates. Race, insurance, and socioeconomic status have been associated with mortality in EGS patients. Acute care surgery (ACS) models have previously shown improved outcomes for EGS patients. We hypothesized that transition to an ACS model would increase access to care for underserved and higher risk EGS patients in a community hospital, without a change in mortality., Methods: This retrospective cohort study included adult EGS patients from 2017 to 2021 with current procedural terminology (CPT) codes of colectomy, small-bowel resection, peptic-ulcer surgery, appendectomy, or cholecystectomy. In July 2020, the hospital transitioned from a traditional model to an ACS model. Patients were analyzed for 42-month before (pre-ACS) and 18-month after (post-ACS) transition. Primary outcome was mortality; secondary outcomes were 30-day postoperative emergency department visits and readmission., Results: We analyzed 467 pre-ACS and 238 post-ACS patients. After transition, patients were more likely to be Black, older, self-pay, and have higher Elixhauser Comorbidity Index (ECI) scores. Rates of cholecystectomies increased and appendectomies decreased after transition. Adjusting for age, race, and ECI, there were no changes in 30-day all-cause mortality (0.9% versus 2.1%, P = 0.63), length of stay (2.7-days versus 3-days, P = 0.91) and rate of postop emergency department visits (7.5% versus 11.3%, P = 0.16). There was a significant increase in hospital readmission after the ACS transition (5.1 versus 10.5%, P = 0.001, odds ratio 5.3)., Conclusions: After implementation of an ACS model, we found an increase in EGS patients who were older, Black, underinsured, with higher ECI without change in mortality. Implementation of ACS models at community hospitals may increase access to quality care for underserved and higher risk patient populations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair., Methods: A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses., Results: 176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts., Conclusions: This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life., 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: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers., Methods: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded., Results: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF., Conclusion: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach., Level of Evidence: Therapeutic/Care Management; Level V., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence., Materials and Methods: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI., Results: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model., Conclusion: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH., Competing Interests: Declaration of Competing Interest The authors have no conflicts to report, (Copyright © 2023. Published by Elsevier Ltd.)

Background: Intercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF)., Methods: SSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation., Results: 241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05)., Conclusion: Intercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications., Competing Interests: Declaration of Competing Interest Dr Bradley W Thomas is an educational consultant for Zimmer Biomedical. Dr Sean T Dieffenbaugher is a speaker for DePuy Synthes. No other conflicts of interest or disclosures exist for the remaining authors. No funding in any form was obtained for this study., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH)., Methods: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence., Results: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model., Conclusion: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters., Competing Interests: Declaration of competing interest The authors have no financial conflicts of interest to disclose., (Copyright © 2022. Published by Elsevier Inc.)

Background: The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury., Methods: A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h., Results: There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021)., Conclusion: Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources., Methods: We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients., Results: Of 14 714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different ( P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts ( P < .05)., Conclusions: EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.

Manure can be a source of antibiotic resistance genes (ARGs) that enter the soil. However, previous studies assessing ARG persistence in soil have generally lacked continuity over sampling times, consistency of location, and assessing the impact of discontinuing manure application. We evaluated both short- and long-term ARG accumulation dynamics in soil with a 40-year known history of manure use. Manure application caused a greater abundance of tetracycline, macrolide, and sulfonamide ARGs in the soil. There was an initial spike in ARG abundance resulting from manure bacteria harboring ARGs being introduced to soil, followed by resident soil bacteria out-competing them, which led to ARG dissipation within a year. However, over four decades, annual manure application caused linear or exponential ARG accumulation, and bacteria associated with ARGs differed compared to those in the short term. Eleven years after discontinuing manure application, most soil ARG levels declined but remained elevated. We systematically explored the historical accumulation of ARGs in manured soil, and provide insight into factors that affect their persistence., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests, Trevor Alexander reports financial support was provided by Canada and Alberta Agriculture and Forestry., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Warfarin is a widely used anticoagulant, and has a narrow therapeutic range. Dosing of warfarin should be individualized, since slight overdosing or underdosing can have catastrophic or even fatal consequences. Despite much research on warfarin dosing, current dosing protocols do not live up to expectations, especially for patients sensitive to warfarin. We propose a deep reinforcement learning-based dosing model for warfarin. To overcome the issue of relatively small sample sizes in dosing trials, we use a Pharmacokinetic/ Pharmacodynamic (PK/PD) model of warfarin to simulate dose-responses of virtual patients. Applying the proposed algorithm on virtual test patients shows that this model outperforms a set of clinically accepted dosing protocols by a wide margin. We tested the robustness of our dosing protocol on a second PK/PD model and showed that its performance is comparable to the set of baseline protocols., Competing Interests: Declaration of Competing Interest 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., (Copyright © 2022 Elsevier Inc. All rights reserved.)

In orchard systems, organic amendments and cover crops may enhance soil organic carbon (SOC) and total nitrogen (STN) stocks, but on a global scale a comprehensive understanding of these practices is needed. This study reports a worldwide meta-analysis of 131 peer-reviewed publications, to quantify potential SOC and STN accumulation in orchard soils induced by organic fertilization and cover cropping. Annual gains of 3.73 Mg C/ha and 0.38 Mg N/ha were realized with the introduction of organic fertilizer, while cover crop management led to annual increases of 2.00 Mg C/ha and 0.20 Mg N/ha. The SOC and STN accumulation rates depended mostly on climatic conditions and initial SOC and STN content. The SOC and STN accumulated fastest during the first three years of cover crop implementation, at 2.98 Mg C/ha/yr and 0.25 Mg N/ha/yr and declined thereafter. Organic fertilization caused significantly more annual SOC and STN accumulation at higher (400-800 mm) than lower (<400 mm) rainfall levels. When cover cropping for more than five years, SOC accumulated the fastest with <800 mm of mean annual rainfall. Organic fertilization led to faster SOC accumulation with mean annual temperature between 15 and 20 °C than >20 °C. Organic amendments led to the slowest SOC accumulation rate when the initial SOC concentration was <10 g C/kg. This study provides policy makers and orchard managers science-based evidence to help guide adaptive management practices that build SOC stocks, improve soil conditions and enhance resilience of orchard systems to climate change., Competing Interests: Declaration of competing interest 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., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints., Methods: An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality., Results: There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively., Conclusion: Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Surgical stabilization of rib fractures (SSRF) has been correlated with improved outcomes, including decreased length of stay (LOS). We hypothesized that an SSRF consultation service would increase the frequency of SSRF and improve outcomes., Methods: A prospective observational study was performed to compare outcomes before and after implementing an SSRF service. Primary outcome was time from admission to surgery; secondary outcomes included LOS, mortality and morphine milligram equivalents (MME) prescribed at discharge., Results: 1865 patients met consultation criteria and 128 patients underwent SSRF. Mortality decreased (6.3% vs. 3%) and patients were prescribed fewer MME at discharge (328 MME vs. 124 MME) following implementation. For the operative cohort, time from admission to surgery decreased by 1.72 days and ICU LOS decreased by 2.6 days., Conclusion: Establishment of an SSRF service provides a mechanism to maximize capture and evaluation of operative candidates, provide earlier intervention, and improve patient outcomes. Additional study to determine which elements and techniques are most beneficial is warranted., Level of Evidence: III., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Soil salinization is a widespread problem affecting global food production. Phytoremediation is emerging as a viable and cost-effective technology to reclaim salt-affected soil. However, its efficiency is not clear due to the uncertainty of plant responses in saline soils. The main objective of this paper is to propose a phytoremediation dynamic model (PDM) for salt-affected soil within the process-based biogeochemical denitrification-decomposition (DNDC) model. The PDM represents two salinity processes of phytoremediation: plant salt uptake and salt-affected biomass growth. The salt-soil-plant interaction is simulated as a coupled mass balance equation of water and salt plant uptake. The salt extraction ability by plant is a combination of salt uptake efficiency (F) and transpiration rate. For water filled pore space (WFPS), the statistical measures RMSE, MAE, and R 2 during the calibration period are 2.57, 2.14, and 0.49, and they are 2.67, 2.34, and 0.56 during the validation period, respectively. For soil salinity, RMSE, MAE, and R 2 during the calibration period are 0.02, 0.02, and 0.92, and 0.06, 0.04, and 0.68 during the validation period, respectively, which are reasonably good for further scenario analysis. Over the four years, cumulative salt uptake varied based on weather conditions. At the optimal salt uptake efficiency (F = 20), cumulative salt uptake from soil was 16-90% for alfalfa, 11-70% for barley, and 10-80% for spring wheat. While at the lowest salt uptake efficiency (F = 40), cumulative salt uptake was nearly zero for all crops. Although barley has the highest peak transpiration flux, alfalfa and spring wheat have greater cumulative salt uptake because their peak transpiration fluxes occurred more frequently than in barley. For salt-tolerant crops biomass growth depends on their threshold soil salinity which determines their ability to take up salt without affecting biomass growth. In order to phytoremediate salt-affected soil, salt-tolerant crops having longer duration of crop physiological stages should be used, but their phytoremediation effectiveness will depend on weather conditions and the soil environment., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Supplementing beef cattle with 3-nitrooxypropanol (3-NOP) decreases enteric methane production, but it is unknown if fertilizing soil with 3-NOP manure influences soil health. We measured soil health indicators 2 yr after manure application to a bromegrass (Bromus L.) and alfalfa (Medicago sativa L.) mixed crop. Treatments were: composted conventional manure (without supplements); stockpiled conventional manure; composted manure from cattle supplemented with 3-NOP; stockpiled 3-NOP manure; composted manure from cattle supplemented with 3-NOP and monensin (3-NOP+Mon), a supplement that improves digestion; stockpiled 3-NOP+Mon manure; inorganic fertilizer (150 kg N ha -1 and 50 kg P ha -1 ); and an unamended control. Select chemical (K + , Mg 2+ , Mn + , Zn + , pH, and Olsen-P), biological (soil organic matter, active C, respiration, and extractable protein), physical (wet aggregate stability, bulk density, total porosity, and macro-, meso-, and micro-porosity), and hydraulic (saturation, field capacity, wilting point, water holding capacity, and hydraulic conductivity) variables were measured. The inclusion of monensin decreased soil Zn + concentrations by 70% in stockpiled 3-NOP+Mon compared with stockpiled conventional manure. Active C and protein in composted conventional manure were 37 and 92% higher compared with stockpiled manure, respectively, but did not vary between 3-NOP treatments. 3-Nitrooxypropanol did not significantly alter other soil health indicators. Our results suggest that composted and stockpiled 3-NOP manure can be used as a nutrient source for forage crops without requiring changes to current manure management because it has minimal influence on soil health., (© 2021 The Authors. Journal of Environmental Quality published by Wiley Periodicals LLC on behalf of American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America.)

Background: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management., Methods: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee., Results: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869)., Conclusion: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups., Level of Evidence: Therapeutic/care management, Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Soil salinity restricts plant growth, affects soil water balance and nitrous oxide (N 2 O) fluxes and can contaminate surface and groundwater. In this study, the Denitrification Decomposition (DNDC) model was modified to couple salt and water balance equations (SALT-DNDC) to investigate the effect of salinity on water balance and N 2 O fluxes. The model was examined against four growing seasons (2008-11) of observed data from Lethbridge, Alberta, Canada. Then, the model was used to simulate water filled pore space (WFPS), salt concentration and the N 2 O flux from agricultural soils. The results show that the effects of salinity on WFPS vary in different soil layers. Within shallow soil layers (<20 cm from soil surface) the salt concentration does not affect the average WFPS when initial salt concentrations range from 5 to 20 dS/m. However, in deeper soil layers (>20 cm from soil surface), when the initial salt concentration ranges from 5 to 20 dS/m it could indirectly affect the average WFPS due to changes of osmotic potential and transpiration. When AW is greater than 40%, the average growing season N 2 O emissions increase to a range of 0.6-1.0 g-N/ha/d at initial salt concentrations (5-20 dS/m) from a range of 0.5-0.7 g-N/ha/d when the salt concentrations is 0 dS/m. The newly developed SALT-DNDC model provides a unique tool to help investigate interactive effects among salt, soil, water, vegetation, and weather conditions on N 2 O fluxes., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

The investigative material 3-nitrooxypropanol (3-NOP) can reduce enteric methane emissions from beef cattle. North American beef cattle are often supplemented the drug monensin to improve feed digestibility. Residual and confounding effects of these additives on manure greenhouse gas (GHG) emissions are unknown. This research tested whether manure carbon and nitrogen, and GHG and ammonia emissions, differed from cattle fed a typical finishing diet and 3-NOP [125-200 mg kg -1 dry matter (DM) feed], or both 3-NOP (125-200 mg kg -1 DM) and monensin (33 mg kg -1 DM) together, compared to a control (no supplements) when manure was stockpiled or composted for 202 days. Consistent with other studies, cumulative GHGs (except nitrous oxide) and ammonia emissions were higher from composted compared to stockpiled manure (all P < 0.01). Dry matter, total carbon and total nitrogen mass balance estimates, and cumulative GHG and ammonia emissions, from stored manure were not affected by 3-NOP or monensin. During the current experiment, supplementing beef cattle with 3-NOP did not significantly affect manure GHG or NH 3 emissions during storage under the tested management conditions, suggesting supplementing cattle with 3-NOP does not have residual effects on manure decomposition as estimated using total carbon and nitrogen losses and GHG emissions.

Background: Critically ill patients on enteral nutrition (EN) often do not receive goal nutrition support. Factors impeding delivery of EN include interruption for procedures, tube dislodgement, and high gastric residuals. A volume-based feeding protocol (VP) is designed to adjust the infusion rate to compensate for interruptions. We hypothesize that implementation of a VP would increase delivery of EN over the conventional hourly rate method (CM)., Methods: This study compared patients on CM to those on VP. The primary outcome measured was percentage of goal EN delivered during the entire intensive care unit (ICU) stay. Inclusion criteria for the study consisted of patients aged >18 years, traumatic mechanism of injury and admission to the ICU >72 hours, hemodynamic stability to receive EN per the trauma ICU standard of practice, and EN via nasogastric or post-pyloric feeding tube., Results: We evaluated 227 patients over a 20-month period. Seventy-nine patients in the VP group were compared with the control group of 148 patients. Patients on VP received a significantly higher percentage of goal EN than those on CM (73.3% vs 65%, P = .0002). There was no difference in the incidence of diarrhea (CM 4.16% vs VP 5.19%; P = .29) or tube dislodgment (CM 2.04% vs VP 1.61%; P = .51)., Conclusion: Implementation of a VP significantly increased delivery of EN by 8.3% over that given by the CM in critically ill trauma patients with no difference in feeding-related complications., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Background: The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma health care (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the intensive care unit to discharge., Methods: Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n = 60) to those in the first full year following implementation (n = 70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Scale score less than 8 on postinjury Day 2, all paraplegic and quadriplegic patients, and patients older than 55 years with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality., Results: The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. Thirty-day readmission and mortality rates remained unchanged. A cost savings of US $11,238 per index hospitalization was observed., Conclusion: In the year following the initiation of the mPATH team, we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared with our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality., Level of Evidence: Therapeutic/care management, Level III.

Traumatic intraperitoneal bladder rupture (IBR) requires surgical repair. Traditionally performed via laparotomy, experience with laparoscopic bladder repair (LBR) after blunt trauma is limited. Benefits of laparoscopy include decreased length of stay (LOS), less pain, early return to work, fewer adhesions, and lower risk of incisional hernia. The aim of this series is to demonstrate the potential superiority of LBR in select trauma patients. This is a retrospective review performed of all IBR patients from 2008 to 2016. Demographics, clinical management, outcomes, and follow-up were compared between LBR and open bladder repair (OBR) patients. Twenty patients underwent OBR, and seven underwent LBR. There was no significant difference in gender, age, or Injury Severity Score. There were no deaths or reoperations in either group. Average hospital length of stay and ICU days were similar between groups. There was one patient with UTI and one with readmission in each group. There were two incisional hernias and two bowel obstructions in the OBR group, with one patient requiring operative intervention. No such complications occurred in the LBR group. LBR for traumatic IBR can be safely performed in select patients, even in those with multiple extra-abdominal injuries.

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11-1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group ( P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

Given the rising nitrous oxide (N 2 O) concentration in the atmosphere, it has become increasingly important to identify hot spots and hot moments of N 2 O emissions. With field measurements often failing to capture the spatiotemporal dynamics of N 2 O emissions, estimating them with modeling tools has become an attractive alternative. Therefore, we incorporated several semi-empirical equations to estimate N 2 O emissions with the Soil and Water Assessment Tool from nitrification and denitrification processes in soil. We then used the model to simulate soil moisture and the N 2 O flux from grassland soils subjected to long-term grazing (> 60 years) at different intensities in Alberta, Canada. Sensitivity analysis showed that parameters controlling the N 2 O flux from nitrification were most sensitive. On average, the accuracy of N 2 O emission simulations were found to be satisfactory, as indicated by the selected goodness-of-fit statistics and predictive uncertainty band, while the model simulated the soil moisture with slightly higher accuracy. As expected, emissions were higher from the plots with greater grazing intensity. Scenario analysis showed that the N 2 O emissions with the recommended fertilizer rate would dominate the emissions from the projected wetter and warmer future. The combined effects of fertilization and wetter and warmer climate scenarios would increase the current N 2 O emission levels by more than sixfold, which would be comparable to current emission levels from agricultural soils in similar regions.

Introduction: We hypothesized that a pH of <7.0 on presentation would correlate with almost universal mortality in trauma patients., Methods: A retrospective cohort study was performed on a Level I trauma center registry from 2013 to 2014. Hospital mortality was the primary outcome, which was compared by pH cohort (<7.0 or ≥7.0) using standard univariate statistics and multivariate logistic regression., Results: There were 593 patients included in the analysis: 66 in <7.0, 527 in ≥7.0. Mortality was 3× higher in the <7.0 pH cohort (62.1 vs. 20.3%; p < 0.0001), however there was no threshold for a pH below which there was 100% mortality. After controlling for these confounding variables, initial pH was found to be an independent predictor of inpatient mortality: pH < 7.0 (OR 6.33, 3.29-12.19; p < 0.0001)., Conclusion: This data indicates that while patients with severe acidosis are at increased risk for mortality, a pH < 7.0 is still recoverable in select cases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

While some countries disaggregate N 2 O emission factors for urine and dung deposited onto pastures, in Canada, distinct N 2 O emission factors for beef cattle urine and dung have not been defined. To help address this knowledge gap, we conducted a 1-year study to quantify N 2 O fluxes from beef cattle urine and dung patches on a semiarid tame pasture in western Canada, as well as to quantify the N 2 O emission factors (EF3) for urine and dung as the percentage of applied N emitted as N 2 O-N. Urine and dung were deposited when soil water-filled pore space was nearly 60%, a wet soil condition for the grazing season in the semiarid study region, which led to a burst of N 2 O from urine in the first 14 days of the study (42% of total N emitted). Urine emitted more cumulative N 2 O (P < 0.001) and had a greater N 2 O emission factor (P = 0.002) than dung. The urine patch emitted 1.30 ± 0.47 g N 2 O-N m -2  year -1 , while the dung patch emitted 0.083 ± 0.020 g N 2 O-N m -2  year -1 (mean values ± SD). The N 2 O emission factor for urine was 1.32 ± 0.49%, while for dung it was 0.03 ± 0.02%. We conclude that more study is needed to determine if distinct N 2 O emission factors are required for urine and dung deposited onto pasture in western Canada to more accurately estimate national N 2 O inventories.

Application of chemical fertilizer or manure can affect soil microorganisms directly by supplying nutrients and indirectly by altering soil pH. However, it remains uncertain which effect mostly shapes microbial community structure. We determined soil bacterial diversity and community structure by 454 pyrosequencing the V1-V3 regions of 16S rRNA genes after 7-years (2007-2014) of applying chemical nitrogen, phosphorus and potassium (NPK) fertilizers, composted manure or their combination to acidic (pH 5.8), near-neutral (pH 6.8) or alkaline (pH 8.4) Eutric Regosol soil in a maize-vegetable rotation in southwest China. In alkaline soil, nutrient sources did not affect bacterial Operational Taxonomic Unit (OTU) richness or Shannon diversity index, despite higher available N, P, K, and soil organic carbon in fertilized than in unfertilized soil. In contrast, bacterial OTU richness and Shannon diversity index were significantly lower in acidic and near-neutral soils under NPK than under manure or their combination, which corresponded with changes in soil pH. Permutational multivariate analysis of variance showed that bacterial community structure was significantly affected across these three soils, but the PCoA ordination patterns indicated the effect was less distinct among nutrient sources in alkaline than in acidic and near-neural soils. Distance-based redundancy analysis showed that bacterial community structures were significantly altered by soil pH in acidic and near-neutral soils, but not by any soil chemical properties in alkaline soil. The relative abundance (%) of most bacterial phyla was higher in near-neutral than in acidic or alkaline soils. The most dominant phyla were Proteobacteria (24.6%), Actinobacteria (19.7%), Chloroflexi (15.3%) and Acidobacteria (12.6%); the medium dominant phyla were Bacterioidetes (5.3%), Planctomycetes (4.8%), Gemmatimonadetes (4.5%), Firmicutes (3.4%), Cyanobacteria (2.1%), Nitrospirae (1.8%), and candidate division TM7 (1.0%); the least abundant phyla were Verrucomicrobia (0.7%), Armatimonadetes (0.6%), candidate division WS3 (0.4%) and Fibrobacteres (0.3%). In addition, Cyanobacteria and candidate division TM7 were more abundant in acidic soil, whereas Gemmatimonadetes, Nitrospirae and candidate division WS3 were more abundant in alkaline soil. We conclude that after 7-years of fertilization, soil bacterial diversity and community structure were shaped more by changes in soil pH rather than the direct effect of nutrient addition.

Limited information is available about soil nitrous oxide (NO) fluxes, NO emission factors (EFs), and yield-scaled NO emissions for biogas residues used to fertilize crops in semiarid regions. To address this knowledge gap, a 4-yr field experiment was conducted in a semiarid climate to determine growing season NO fluxes from soil receiving (i) anaerobically digested solid beef cattle manure (digestate), (ii) separated solids from the digestate (separated solids), and (iii) undigested solid beef cattle manure (cattle manure) applied to target one and two times the recommended rates (200 and 400 kg total N ha) for barley ( L.) forage, assuming 50% of N was annually plant available. Nitrous oxide fluxes were determined using vented static chambers. Over the four growing seasons, 95, 80, and 81% of the NO flux occurred within 36 d of applying digestate, separated solids, and cattle manure, respectively. The cumulative NO emissions with digestate were 4.7 and 4.1 times the values of the separated solids and cattle manure, respectively. The digestate NO EF was 13.6 and 10.6 times the values of the separated solids and cattle manure, respectively, but the NO EF based on applied mineral N was similar for all amendments. The yield-scaled NO emissions with digestate were 4.3 and 3.6 times the values of the separated solids and cattle manure, respectively. In the semiarid region of southern Alberta, liquid biogas residues have a higher risk for NO emissions than both the separated solid fraction of the biogas residues and undigested cattle manure., (Copyright © by the American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America, Inc.)

Background: Permanent neurologic injury in pediatric patients with burner and stinger syndrome (BSS) is unlikely. This study aims to assess the feasibility of clinical observation without extensive radiologic workup in this selective population., Methods: A retrospective study was conducted of patients aged younger than 18 years evaluated at a level I trauma center from 2012 to 2014. Patients were grouped according to positive deficit (PD) or negative deficit (ND) upon physical examination. Demographics, clinical findings, and outcomes were analyzed., Results: Thirty patients (ND, n = 14; PD, n = 16) were evaluated for BSS, most often as a result of injurious football tackle. Age and length of stay were similar between groups. Injury Severity Score was lower in the ND group than the PD group (1.6 ± 1.2 vs 3.8 ± 3.1, respectively; P< .05). Cervical computed tomography was performed on 11 patients (78.6%) in the ND group and 15 patients (93.8%) in the PD group at considerable added cost, with only 1 positive result in the ND group and none in the PD group. Magnetic resonance imaging (MRI) revealed 2 positive findings in each group, and no surgical interventions were indicated. Ten ND (71.4%) and 12 PD (75%) patients reported complete resolution of symptoms at discharge (P> .05)., Conclusions: Children presenting with BSS experience temporary symptoms that resolve without surgical intervention. Magnetic resonance imaging identified more injuries than computed tomographic imaging; therefore, we suggest that management for BSS should include observation, serial neurologic examinations, and MRI evaluation as appropriate., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: The authors present a novel approach to nonresectional therapy in major hepatic trauma utilizing intraabdominal perihepatic vacuum assisted closure (VAC) therapy in the porcine model of Grade V liver injury., Methods: A Grade V injury was created in the right lobe of the liver in a healthy pig. A Pringle maneuver was applied (4.5 minutes total clamp time) and a vacuum assisted closure device was placed over the injured lobe and connected to suction. The device consisted of a perforated plastic bag placed over the liver, followed by a 15 cm by 15cm VAC sponge covered with a nonperforated plastic bag. The abdomen was closed temporarily. Blood loss, cardiopulmonary parameters and bladder pressures were measured over a one-hour period. The device was then removed and the animal was euthanized., Results: Feasibility of device placement was demonstrated by maintenance of adequate vacuum suction pressures and seal. VAC placement presented no major technical challenges. Successful control of ongoing liver hemorrhage was achieved with the VAC. Total blood loss was 625 ml (20ml/kg). This corresponds to class II hemorrhagic shock in humans and compares favorably to previously reported estimated blood losses with similar grade liver injuries in the swine model. No post-injury cardiopulmonary compromise or elevated abdominal compartment pressures were encountered, while hepatic parenchymal perfusion was maintained., Conclusion: These data demonstrate the feasibility and utility of a perihepatic negative pressure device for the treatment of hemorrhage from severe liver injury in the porcine model.

Ventilator-associated pneumonia (VAP) is a common problem in an intensive care unit (ICU), although the incidence is not well established. This study aims to compare the VAP incidence as determined by the treating surgical intensivist with that detected by the hospital Infection Control Service (ICS). Trauma and surgical patients admitted to the surgical critical care service were prospectively evaluated for VAP during a 5-month time period. Collected data included the surgical intensivist's clinical VAP (SIS-VAP) assessment using Centers for Disease Control and Prevention (CDC) VAP criteria. As part of the hospital's VAP surveillance program, these patients' medical records were also reviewed by the ICS for VAP (ICS-VAP) using the same CDC VAP criteria. All patients suspected of having VAP underwent bronchioalveolar lavage (BAL). The SIS-VAP and ICS-VAP were then compared with BAL-VAP. Three hundred twenty-nine patients were admitted to the ICU during the study period. One hundred thirty-three were intubated longer than 48 hours and comprised our study population. Sixty-two patients underwent BAL evaluation for the presence of VAP on 89 occasions. SIS-VAP was diagnosed in 38 (28.5%) patients. ICS-VAP was identified in 11 (8.3%) patients (P < 0.001). The incidence of VAP by BAL criteria was 23.3 per cent. When compared with BAL, SIS-VAP had 61.3 per cent sensitivity and ICS-VAP had 29 per cent sensitivity. VAP rates reported by hospital administrative sources are significantly less accurate than physician-reported rates and dramatically underestimate the incidence of VAP. Proclaiming VAP as a never event for critically ill for surgical and trauma patients appears to be a fallacy.

Background: Scheduled repeat brain CT (SRBCT) is used to monitor progression of traumatic brain injury (TBI). Previous studies have suggested that routine SRBCT can be replaced by an unscheduled repeat brain CT after deterioration on serial neurological examination. In this study, we evaluated if SRBCT has a role in the management of TBI., Study Design: Retrospective observational study of 1,019 consecutive adult patients admitted to a Level I trauma center with CT evidence of TBI on initial brain CT (IBCT). All patients with intracranial pathology on IBCT were scheduled for SRBCT and underwent sequential neurological physical examinations. Interventions (surgical or medical) after IBCT, SRBCT, or neurological change were recorded., Results: One thousand nineteen patients with IBCT evidence of TBI were identified from the trauma registry during a 50-month study period beginning in November 2001. Eighty-six (8.9%) of these patients went directly for craniotomy. After exclusions, 887 patients were analyzed. A total of 692 (78%) patients had a no worse first SRBCT and neurologic changes requiring intervention later developed in 11 (1.6%) of these patients. One hundred ninety-five (22%) patients had a worse first SRBCT, with 14 (7.2%) requiring immediate intervention. Seven (3.6%) worse first SRBCT patients had a subsequent SRBCT that worsened, leading to an intervention. A neurologic change that precipitated an intervention developed subsequently in an additional 19 (9.7%) patients with a worse first SRBCT. Chi-square analysis demonstrated that a first SRBCT that was worse was more likely to result in an intervention than if the first SRBCT was no worse., Conclusions: A worse SRBCT is more likely to result in neurologic intervention. SRBCT remains useful in assessing patients with TBI., (Copyright 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Allogenic blood product transfusion and organ donation are critical components of modern medicine. However, only 5 per cent of the eligible population donate blood and only 53 per cent declare themselves organ donors. Trauma surgeons have an intimate exposure to these needs and their personal donation patterns may reflect this knowledge. A 14 question survey about personal blood and organ donation was sent to 635 members of the American Association for the Surgery of Trauma by e-mail. Seventy-eight per cent of respondents have donated blood and 86 per cent of those donors have done so repeatedly. However, 83 per cent of respondents have not given blood in the past year. Medical reasons were the most common reason cited for inability to donate (45%). With regard to organ donation, 90 per cent of respondents have filled out the organ donation section on their driver's license and 89 per cent have discussed organ donation with their family. The rates of blood and organ donation are higher than the rates of the general population. Trauma surgeons are likely to be blood and organ donors. Their intimate knowledge of the importance of donation plays a role. Personal medical conditions that restrict donation were, among respondents, a more common cause of failure to donate than were time constraints.