Eubacterium callanderi bacteremia: A case report.

Eubacterium species are a group of obligated anaerobic gram-positive bacilli that are recognized as commensals of the gastrointestinal tract flora. Cases of bacteremia mediated by Eubacterium are rare. This report describes a case of bacteremia caused by Eubacterium callanderi in an 82-year-old female with a history of a cecal perforation secondary to an obstructing sigmoid stricture. The results showed the utility of using whole genome sequencing to identify the causative agent and underlined the significance to identify anaerobic organisms in diagnostic microbiology practice and to perform antimicrobial susceptibility testing to guide therapy and enhance patient outcomes.

Sternal fixation for traumatic sternal fractures demonstrates better long-term quality of life outcomes than nonoperative management: A survey analysis.

INTRODUCTION: Sternal fractures are rare, causing significant pain, respiratory compromise, and decreased upper extremity range of motion. Sternal fixation (SF) is a viable treatment option; however, there remains a paucity of literature demonstrating long-term benefits. This study examined long-term outcomes of SF, hypothesizing they have better long-term quality of life (QoL) than patients managed nonoperatively (NOM). METHODS: This was a survey study at our level 1 academic hospital. All patients diagnosed with a sternal fracture were included from January 2016 to July 2021. Patients were grouped whether they received SF or NOM. Basic demographics were obtained. Three survey phone call attempts were conducted. The time from injury to survey was recorded. Outcomes included responses to the QoL survey, which included mobility, self-care, usual activities, chest pain/discomfort, and anxiety/depression. The survey scale is 1-5 (1 = worst condition possible; 5 = best possible condition). Patients were asked to rate their current health on a scale of 0-100 (100 being the best possible health imaginable). Chi square and t-tests were used. Significance was set at p < 0.05. RESULTS: Three hundred eighty four patients were surveyed. Sixty nine underwent SF and 315 were NOM. Thirty-eight (55.1%) SF patients and 126 (40%) NOM patients participated in the survey. Basic demographics were similar. Average days from sternal fracture to survey was 1198 (±492) for the SF group and 1454 (±567) for the NOM group. The SF cohort demonstrated statistically significant better QoL than the NOM cohort for all categories except anxiety/depression. CONCLUSION: SF provides better long-term QoL and better overall health scores compared to NOM.

Kids gone wild - Alcohol use and patient characteristics in pediatric trauma during the coronavirus disease 2019 pandemic.

Importance: Reported coronavirus disease 2019 (COVID-19) pandemic effects on pediatric trauma have been variable. Objective: We investigated the characteristics of pediatric trauma including alcohol use during the pandemic at our urban trauma center. Methods: The trauma database of our adult level 1 trauma center was queried for all pediatric (age ≤ 18 years) patients presenting between March 1, 2020, and October 30, 2020. Data from 2017 to 2019 served as a control. Variables analyzed included demographics, mechanisms, injury severity, hospitalization characteristics, and positive blood alcohol. Results: Pandemic pediatric trauma volumes increased by 67.5% (330/year vs. 197/year). Pandemic patients were younger (median age 13 vs. 14 years, P = 0.011), but similar in gender, ethnicity, severity, hospital length of stay, mortality, and rates of penetrating injury. Falls doubled (79/year vs. 34/year) and shifted away from high falls >6 meters (0% vs. 7.9%) to moderate falls 1-6 meters (58.2% vs. 51.5%) (P = 0.028). Transportation injury rates were similar however mechanisms shifted from motor vehicle crashes (-13.5%) towards recreational vehicles including motorcycles (+2.1%), all-terrain vehicles (+8.6%), and bicycles (+3.8%) (P = 0.018). Pediatric-positive blood alcohol was significantly higher (11.2% vs. 5.1%, P < 0.001), especially for ages 14-18 years (21.7% vs. 9.5%, P < 0.001). Interpretation: Pediatric trauma volumes during the COVID-19 pandemic increased. Pandemic patients had more recreational vehicle injuries and higher rates of positive blood alcohol. This suggests an increased need for alcohol assessment and targeted interventions in the pediatric population during pandemics or periods of school closures.

Better late than never-a single-center review of delayed rib fixation for symptomatic rib fractures and nonunions.

BACKGROUND: Surgical stabilization of rib fractures (SSRFs) has become an emerging therapy for treatment of patients with rib fractures. More commonly, it is used in the acute setting; however, delayed SSRF can be utilized for symptomatic rib fracture nonunions. Here, we describe our institution's experience with delayed SSRF, hypothesizing it is safe and resolves patient symptoms. METHODS: This is a retrospective review of patients presenting to our Level I trauma center to undergo delayed SSRF for symptomatic nonunions from January 2017 to September 2022. Delayed SSRF was defined as SSRF over 2 weeks in the outpatient setting. Basic demographics were obtained. Outcomes of interest included mean pain score (preoperatively and postoperatively), intensive care unit (ICU) and hospital length of stay (LOS), and resolution of preoperative symptoms, specifically chest wall instability, with return to activities of daily living (ADLs). RESULTS: Forty-four patients met inclusion criteria with a total of 156 symptomatic nonunion rib fractures that received delayed SSRF. The average age was 59.2 ± 11.9 years and median number of days from injury to SSRF was 172.5 (interquartile range, 27.5-200). The average number rib fractures plated per patient 3.5 ± 1.8. Only three patients required ICU admission postoperatively for no longer than 2 days. Median hospital LOS was 2 days (interquartile range 1-3 days). Average preoperative and postoperative pain score was 6.8 ± 1.9 and 2.02 ± 1.5, respectively ( p < 0.001). Chest wall instability and preoperative symptoms resolved in 93.2% of patients postoperatively ( p < 0.001). Two patients (4.5%) had postoperative complications that resolved after additional surgical intervention. Rib fracture healing was demonstrated on radiographic imaging during postoperative follow-up. CONCLUSION: Delayed SSRF is safe and demonstrates significant resolution of preoperative symptoms by decreasing pain, improving chest wall stability, and allowing patients to return to activities of daily living. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Surgical stabilization of rib fractures is associated with better return on investment for a health care institution than nonoperative management.

BACKGROUND: Surgical stabilization of rib fractures (SSRFs) continues to gain popularity due to patient benefits. However, little has been produced regarding the economic benefits of SSRF and its impact on hospital metrics such as Vizient. The aim of this study was to explore these benefits hypothesizing SSRF will demonstrate positive return on investment (ROI) for a health care institution. METHODS: This is a retrospective review of all rib fracture patients over 5 years at our Level I trauma center. Patients were grouped into SSRF versus nonoperative management. Basic demographics were obtained including case mix index (CMI). Outcomes included narcotic requirements in morphine milliequivalents prior to discharge, mortality, and discharge disposition. Furthermore, actual hospital length of stay (ALOS) versus Vizient expected length of stay were compared between cohorts. Contribution margin (CM) was also calculated. Independent t-test, paired t-test, and linear regression analysis were performed, and significance set at p < 0.05. RESULTS: A total of 1,639 patients were included; 230 (14%) underwent SSRF. Age, gender, and Injury Severity Score were similar. Surgical stabilization of rib fracture patients had more ribs fractured (7 vs. 4; p < 0.001) and more patients with flail chest (43.5% vs. 6.7%; p < 0.001). Surgical stabilization of rib fracture patients also had a significantly higher CMI (4.33 vs. 2.78; p = 0.001). Narcotic requirements and mortality were less in the SSRF cohort; 155 versus 246 morphine milliequivalents ( p < 0.001) and 1.7% versus 7.1% ( p = 0.003), respectively. Surgical stabilization of rib fracture patients were more likely to be discharged home (70.4% vs. 63.7%; p = 0.006). Surgical stabilization of rib fracture patients demonstrated shorter ALOS where nonoperative management patients demonstrated longer ALOS compared with Vizient expected length of stay. Contribution margins for SSRF patients were significantly higher and linear regression analysis showed a CM $1,128.14 higher per patient undergoing SSRF ( p < 0.001). CONCLUSION: Patients undergoing SSRF demonstrate a significant ROI for a health care organization. Despite SSRF patients having a higher CMI, they were able to be discharged sooner than expected by Vizient calculations resulting in better a CM. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Impact of sternal fixation on patient outcomes: A case matched review.

INTRODUCTION: Sternal fractures are debilitating injuries often resulting in severe pain and respiratory compromise. Surgical fixation of sternal fractures is gaining popularity as a treatment modality for sternal fractures. Unfortunately, little literature exists on this topic. This study looks to further examine the benefits of sternal fixation (SF), hypothesizing SF results in improved pain, improved respiratory function, and decreased opioid use. METHODS: Retrospective review was performed between patients with sternal fractures who underwent nonoperative management (NOM) versus operative SF. Case matching was used to construct an artificial control group matched on age and Injury Severity Score using a 1:1 ratio of treatment to control. Exclusion criteria were age younger than 18 years. Outcomes of interest included mean pain score, total opioid requirements (in morphine milliequivalents) within 24 hours of discharge, intensive care unit and hospital length of stay (LOS), and incentive spirometry percent predicted value at discharge. Dependent variables were analyzed using t test, and Injury Severity Score was analyzed using the sign test. Statistical significance was set at p < 0.05. RESULTS: Fifty-eight patients from the SF cohort were matched with 58 patients from the NOM cohort. The average age was 59.8 years for the SF group and 62.2 years for the NOM group. Injury Severity Score was matched at 9 for both cohorts. Although pain scores were similar for both cohorts, the SF group required significantly less opioids at discharge (62.1 vs. 92.2 morphine milliequivalents; p = 0.007). In addition, the SF cohort demonstrated significantly improved respiratory function per incentive spirometry percent predicted value at discharge (75.5% vs. 59.9%; p < 0.001). Intensive care unit LOS and hospital LOS were similar between cohorts. CONCLUSION: Despite similarities in pain scores, intensive care unit LOS, and hospital LOS, SF was associated with decreased opioid requirements and improved respiratory function at discharge in this study. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Focusing in on gallbladder disease. Do current imaging modalities accurately depict the severity of final pathology?

BACKGROUND: Accuracy of imaging modalities for gallbladder disease(GBD) remains questionable. We hypothesize ultrasonography(US), computed tomography(CT), and magnetic resonance imaging(MRI) poorly correlate with final pathologic analysis. METHODS: This was a retrospective review of all patients who underwent cholecystectomy at our institution. Primary outcome was agreement between US, CT, and MRI, and final pathology report of the gallbladder. Cohen's Kappa statistic was used to describe the level of agreement (0 = agreement equivalent to chance, 0.1-0.2 = slight agreement, 0.21-0.40 = minimal/fair agreement, 0.41-0.60 = moderate agreement, 0.61-0.80 = substantial agreement, 0.81-0.99 = near perfect agreement, 1 = perfect agreement). Significance was set at p < 0.05. RESULTS: 1107 patients were enrolled. Average age was 48.6(±17.6); 64.2% were female. There was minimal agreement between the three imaging modalities and final pathology (US = 0.363; CT = 0.223; MRI = 0.351;p < 0.001). CONCLUSION: Poor agreement exists between imaging modalities and final pathology report for GBD. Urgent surgical intervention for patients presenting with symptoms of GBD should be considered, despite imaging results.

Finite element analysis for better evaluation of rib fractures: A pilot study.

INTRODUCTION: Modeling rib fracture stability is challenging. Computer-generated finite element analysis (FEA) is an option for assessment of chest wall stability (CWS). The objective is to explore FEA as a means to assess CWS, hypothesizing it is a reliable approach to better understand rib fracture pathophysiology. METHODS: Thoracic anatomy was generated from standardized skeletal models with internal/external organs, soft tissue and muscles using Digital Imaging and Communications in Medicine data. Material properties were assigned to bone, cartilage, skin and viscera. Simulation was performed using ANSYS Workbench (2020 R2, Canonsburg, PA). Meshing the model was completed identifying 1.3 and 2.1 million elements and nodes. An implicit solver was used for a linear/static FEA with all bony contacts identified and applied. All material behavior was modeled as isotropic/linear elastic. Six load cases were evaluated from a musculoskeletal AnyBody model; forward flexion, right/left lateral bending, right/left axial rotation and 5-kg weight arm lifting. Standard application points, directions of muscle forces, and joint positions were applied. Ten fracture cases (unilateral and bilateral) were defined and 66 model variations were simulated. Forty-three points were applied to each rib in the mid/anterior axillary lines to assess thoracic stability. Three assessment criteria were used to quantify thoracic motion: normalized mean absolute error, normalized root mean square error, and normalized interfragmentary motion. RESULTS: All three analyses demonstrated similar findings that rib fracture deformation and loss of CWS was highest for left/right axial rotation. Increased number of ribs fracture demonstrated more fracture deformation and more loss of CWS compared with a flail chest segment involving less ribs. A single rib fracture is associated with ~3% loss of CWS. Normalized interfragmentary motion deformation can increases by 230%. Chest wall stability can decrease by over 50% depending on fracture patterns. CONCLUSION: Finite element analysis is a promising technology for analyzing CWS. Future studies need to focus on clinical relevance and application of this technology. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level IV.

Impact of Chemoprophylaxis on Thromboembolism Following Operative Fixation of Pelvic Fractures.

BACKGROUND: Venous thromboembolism (VTE) is a common cause of serious morbidity and mortality. While chemoprophylaxis decreases VTE, there is the theoretical risk of increased hemorrhagic complications. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt pelvic fractures requiring operative fixation. METHODS: Patients with blunt pelvic fractures requiring operative fixation over 10.5 years were identified. Patients were stratified by age, severity of shock, operative management, and timing and duration of anticoagulation. Outcomes were evaluated to determine risk factors for bleeding complications and VTE. RESULTS: 310 patients were identified: 212 patients received at least one dose of preoperative anticoagulation and 98 received no preoperative anticoagulation. 68% were male with a mean injury severity score and Glasgow Coma Scale of 26 and 13, respectively. Bleeding complications occurred in 24 patients and 21 patients suffered VTE. Patients with VTE had a greater initial severity of shock (resuscitation transfusions, 4 vs. 2 units, P = .02). Despite longer time to mobilization (4 vs. 3 days, P = .001), patients who received their scheduled preoperative doses within 48 hours of arrival had no significant differences in the number of deep vein thrombosis events (5.2% vs. 5.7%, P = .99), but fewer episodes of pulmonary embolism (PE) (1.5% vs. 6.8%, P = .03) with no difference in bleeding complications (7.5% vs. 8%, P = .87) compared to either patients who had their doses held until after 48 hours of arrival or received no preoperative anticoagulation. DISCUSSION: Preoperative anticoagulation prior to pelvic fixation reduced the risk of PE without increasing bleeding complications. Preoperative anticoagulation is safe and beneficial in this group of patients.

Impact of a simplified management algorithm on outcome following exsanguinating pelvic fractures: A 10-year experience.

BACKGROUND: Optimal management of exsanguinating pelvic fractures remains controversial. Our previous experience suggested that management decisions based on a defined algorithm were associated with a significant reduction in transfusion requirements and mortality. Based on these outcomes, a clinical pathway (PW) for the management of exsanguinating pelvic fractures was developed. The purpose of this study was to evaluate the impact of this PW on outcomes. METHODS: Consecutive patients over 10 years with blunt pelvic fractures subsequent to the implementation of the clinical PW were identified. Patients with hemodynamically unstable pelvic fractures are managed initially with a pelvic orthotic device. For those with continued hemodynamic instability and no extrapelvic source of hemorrhage, pelvic angiography was performed followed by elective pelvic fixation. Patients managed according to the PW were compared with those patients whose management deviated (DEV) from the PW. RESULTS: There were 3,467 patients identified. Three hundred twelve (9%) met entry criteria: 246 (79%) comprised the PW group and 66 (21%) the DEV group. Injury severity, as measured by Injury Severity Score (35 vs. 36; p = 0.55), admission Glasgow Coma Scale (10 vs. 10; p = 0.58), admission BE (-7.4 vs. -6.4, p = 0.38), admission SBP (107 vs. 104, p = 0.53), and PRBC requirements during initial resuscitation (6.1 units vs. 6.6 units, p = 0.22) were similar between the groups. Pelvic orthotic device use was 48% in the DEV group (p < 0.001). Twenty-four percent of the PW group required angiography compared with 74% of the DEV group (p < 0.001). Forty-eight-hour transfusions (11 vs. 16, p = 0.01) and mortality (35% vs. 48%, p = 0.04) were reduced in the PW group compared with the DEV group. Pathway adherence was identified as an independent predictor of both decreased transfusions (ß = -5.8, p = 0.002) via multiple linear regression and decreased mortality (hazard ratio, 0.74; 95% confidence interval, 0.42-0.98) via multivariable cox proportional hazards analysis. CONCLUSION: Adherence to a defined clinical PW simplified the management of exsanguinating pelvic fractures and contributed to a reduction in both transfusion requirements and mortality. LEVEL OF EVIDENCE: Prognostic, level III.