Decreased readmission rates following use of modified trauma-specific frailty index in older trauma patients: A follow-up study.

INTRODUCTION: Post-discharge readmission rates using modified Trauma-Specific Frailty Index (mTSFI) compared to the Emergency Severity Index (ESI) are unknown. In our pilot study, we demonstrated that mTSFI usage more accurately triages older trauma patients. In the current study, we hypothesized that adult trauma patients triaged using mTSFI would have lower readmission rates at the 30-day interval post discharge. METHODS: Retrospective review of readmission rates for 96 trauma patients ≥ 50 years old was performed. The two study groups were categorized as mTSFI-concordant and ESI-concordant. Fisher's exact test was performed. RESULTS: Mean ages for ESI and mTSFI groups were 63.8 (SD 10.6) and 65.2 (SD 10.8) years. The 30-day readmission rate was 0% (0/32) in the mTSFI group vs 11% (7/64) in the ESI group (p = 0.104). CONCLUSIONS: Utilization of mTSFI for adult trauma patients may lead to lower 30-day readmission rates compared to using ESI, despite our sample sizes being too small to demonstrate a statistically significant difference.

A Comparative Analysis of Hospital Triage Systems in the Geriatric Adult Trauma Patients: A Quality Improvement Pilot Study.

BACKGROUND: The objective of our study is to compare the predicted hospital admission disposition based on the level of risk as determined by the modified Trauma-Specific Frailty Index (mTSFI) score with those determined by arbitrary decisions made based on the Emergency Severity Index (ESI) severity level. METHODS: We surveyed 100 trauma patients ages 50 and older, admitted to a level 1 trauma center between April 2019 and July 2019. We retrospectively reviewed the hospital admission disposition of each patient under the ESI, which was then compared to the mTSFI-predicted hospital admission disposition. The mTSFI scores were calculated by surveying each patient. Statistical analysis was performed to identify any statistical significance of concordance and discordance when comparing the mTSFI and ESI. RESULTS: The average age was 57.6 ± 4.2 years old in the non-geriatric group vs 76.3 ± 7.3 years old in the geriatric group. There was a male predominance in both groups (61% vs 69.5%). The mTSFI identified a higher percentage of triage discordance in the non-geriatric group (73%) compared to the geriatric cohort (53%) (95% difference CI, [39.6-40], P = .05). DISCUSSION: Non-geriatric patients have higher recorded rate of frailty than previously recognized and screening should begin at age 50, not 65. The mTSFI may be an effective tool to appropriately triage adult trauma patients at increased risk due to frailty and may reduce in-hospital complications.

Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Awareness of the magnitude of contact sports-related concussions has risen exponentially in recent years. Our objective is to conduct a prospectively registered systematic review of the scientific evidence regarding interventions to prevent contact sports-related concussions. METHODS: Using the Grading of Recommendations Assessment, Development, and Evaluation methodology, we performed a systematic review of the literature to answer seven population, intervention, comparator, and outcomes (PICO) questions regarding concussion education, head protective equipment, rules prohibiting high-risk activity and neck strengthening exercise for prevention of contact sports-related concussion in pediatric and adult amateur athletes. A query of MEDLINE, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded, and all articles reviewed were written in English. RESULTS: Thirty-one studies met the inclusion criteria and were applicable to our PICO questions. Conditional recommendations are made supporting preventive interventions concussion education and rules prohibiting high-risk activity for both pediatric and adult amateur athletes and neck strengthening exercise in adult amateur athletes. Strong recommendations are supported for head protective equipment in both pediatric and adult amateur athletes. Strong recommendations regarding newer football helmet technology in adult amateur athletes and rules governing the implementation of body-checking in youth ice hockey are supported. CONCLUSION: Despite increasing scientific attention to sports-related concussion, studies evaluating preventive interventions remain relatively sparse. This systematic review serves as a call to focus research on primary prevention strategies for sports-related concussion. LEVEL OF EVIDENCE: IV. PROSPERO REGISTRATION NUMBER: #42016043019.

Successful treatment of massive hemothorax with class IV shock using aortography with transcatheter embolization of actively bleeding posterior left intercostal arteries after penetrating left chest trauma: A case for the hybrid OR.

Hemothorax is a common occurrence after blunt or penetrating injury to the chest. Posterior intercostal vessel hemorrhage as a cause of major intrathoracic bleeding is an infrequent source of massive bleeding. Selective angiography with trans-catheter embolization may provide a minimally invasive and efficient method of controlling bleeding refractory to surgical treatment. PRESENTATION OF CASE: A 19 year-old male sustained a gunshot wound to his left chest with massive hemothorax and refractory hemorrhage. He was emergently taken to the operating room for thoracotomy and was found to have uncontrollable bleeding from the chest due to left posterior intercostal artery transection. The bleeding persisted despite multiple attempts with sutures, clips and various hemostatic agents. Thoracic aortography was undertaken and revealed active bleeding from the left 7th posterior intercostal artery, which was coil-embolized. The patient's hemodynamic status significantly improved and he was transferred to the intensive care unit. DISCUSSION: Posterior intercostal bleeding is a rare cause of massive hemothorax. Bleeding from these arteries may be difficult to control due to limited exposure in that area. Transcatheter-based arterial embolization is a reliable and feasible option for arresting hemorrhage following failed attempts at hemorrhage control from thoracotomy. CONCLUSION: Massive hemothorax from intercostal arterial bleeding is a rare complication after penetrating chest injury (Aoki et al., 2003). Selective, catheter-based embolization is a useful therapeutic option for hemorrhage control and can be expeditiously employed if a hybrid operating room is available.

"Black Esophagus" and Gastric Volvulus Following Slipped Laparoscopic Adjustable Gastric Band.

To review the entity "black esophagus" and sequela of a slipped laparoscopic adjustable band. The patient's history, physical examination, imaging, and endoscopic findings were reviewed. Detailed review of pathophysiology, presentation, diagnosis, management, and natural history was conducted. "Black esophagus," also known as acute esophageal necrosis (AEN), is a rare condition resulting in black discoloration of the mid to distal esophagus with less than a hundred reported cases. It has not been previously documented in bariatric surgery or following laparoscopic adjustable gastric banding. The volvulus was reduced at surgery, and the esophageal changes resolved without sequela. "Black esophagus" is an acute, ominous-appearing condition with a spectrum ranging from superficial mucosal disease to transmural involvement with perforation. Fortunately, esophageal resection is rarely required.

Physiologically-based, predictive analytics using the heart-rate-to-Systolic-Ratio significantly improves the timeliness and accuracy of sepsis prediction compared to SIRS.

BACKGROUND: Enhancing the efficiency of diagnosis and treatment of severe sepsis by using physiologically-based, predictive analytical strategies has not been fully explored. We hypothesize assessment of heart-rate-to-systolic-ratio significantly increases the timeliness and accuracy of sepsis prediction after emergency department (ED) presentation. METHODS: We evaluated the records of 53,313 ED patients from a large, urban teaching hospital between January and June 2015. The HR-to-systolic ratio was compared to SIRS criteria for sepsis prediction. There were 884 patients with discharge diagnoses of sepsis, severe sepsis, and/or septic shock. RESULTS: Variations in three presenting variables, heart rate, systolic BP and temperature were determined to be primary early predictors of sepsis with a 74% (654/884) accuracy compared to 34% (304/884) using SIRS criteria (p < 0.0001)in confirmed septic patients. CONCLUSION: Physiologically-based predictive analytics improved the accuracy and expediency of sepsis identification via detection of variations in HR-to-systolic ratio. This approach may lead to earlier sepsis workup and life-saving interventions.

Hospital-based, Multidisciplinary, youth mentoring and medical exposure program positively influences and reinforces health care career choice: "The Reach One Each One Program early Experience".

BACKGROUND: According to the National Center for Educational Statistics, underrepresented minorities (URMs) are more likely to leave science, technology, engineering and mathematics (STEM) fields at higher rates than their peers during undergraduate studies. Many institutions of higher learning have implemented pipeline programs aimed at preparing and inspiring high school and college aged students in select careers in health sciences with varying levels of success. Research has shown that a health care workforce that mirrors the community they serve is more effective in reducing health disparities and increasing positive health outcomes. We hypothesize that a hospital-based, multidisciplinary youth mentoring and medical exposure program will enhance the decision of URM high school students to choose healthcare careers. MATERIALS AND METHOD: A retrospective analysis of the Reach One Each One Program (ROEO) was performed. ROEO is a hospital based, 11-week multidisciplinary youth mentoring and medical exposure program for inner-city high school students. The analysis was based on a phone survey of the twenty-six (26) seniors who completed the program and subsequently graduated from high school between May 2013 and May 2015 to assess the following: 1) College enrollment/attendance, 2) Health profession majors, and 3) Pre-med status. The study was approved by the Morehouse School of Medicine Institutional Review Board. RESULTS: Of the twenty-six students, 23 were female and 3 were male; 25 (96%) of the students were African American and one student was a Caucasian female. Twenty-four (92.3%) of the students were enrolled in college and 2 (7.7%) were scheduled to begin in the spring semester of 2016. Twenty-one of the 24 attending college at the time of the survey (87.5%) were enrolled in a health science degree program and 16 (66.7%) confirmed that they were enrolled in pre-medical (Pre-med) curriculum. CONCLUSION: Hospital-based, multidisciplinary medical mentoring programs can have a positive impact on the lives and health care career decisions of aspiring URM high school students. Further study will be necessary to validate the most influential components needed for the success of such programs.

Vitamin D3 Suppresses Class II Invariant Chain Peptide Expression on Activated B-Lymphocytes: A Plausible Mechanism for Downregulation of Acute Inflammatory Conditions.

Class II invariant chain peptide (CLIP) expression has been demonstrated to play a pivotal role in the regulation of B cell function after nonspecific polyclonal expansion. Several studies have shown vitamin D3 helps regulate the immune response. We hypothesized that activated vitamin D3 suppresses CLIP expression on activated B-cells after nonspecific activation or priming of C57BL/6 mice with CpG. This study showed activated vitamin D3 actively reduced CLIP expression and decreased the number of CLIP(+) B-lymphocytes in a dose and formulation dependent fashion. Flow cytometry was used to analyze changes in mean fluorescent intensity (MFI) based on changes in concentration of CLIP on activated B-lymphocytes after treatment with the various formulations of vitamin D3. The human formulation of activated vitamin D (calcitriol) had the most dramatic reduction in CLIP density at an MFI of 257.3 [baseline of 701.1 (P value = 0.01)]. Cholecalciferol and alfacalcidiol had no significant reduction in MFI at 667.7 and 743.0, respectively. Calcitriol seemed to best reduce CLIP overexpression in this ex vivo model. Bioactive vitamin D3 may be an effective compliment to other B cell suppression therapeutics to augment downregulation of nonspecific inflammation associated with many autoimmune disorders. Further study is necessary to confirm these findings.

Klebsiella pneumoniae Liver Abscess and Metastatic Endophthalmitis.

Introduction. Klebsiella pneumoniae is a well-known cause of liver abscess. Higher rates of liver abscess associated with Klebsiella pneumoniae are seen in Taiwan. Metastatic endophthalmitis is a common complication associated with a poor prognosis despite aggressive therapy. Case Report. We report a case of a 67-year-old Korean female with Klebsiella pneumoniae liver abscess. The patient developed metastatic endophthalmitis and ultimately succumbed to her disease despite aggressive medical and surgical treatment. Conclusion. Dissemination of Klebsiella pneumoniae is associated with significant morbidity and mortality. Liver abscesses preferably should be treated with percutaneous drainage, but surgical treatment is needed in some cases. Metastatic spread to the eye is a common complication that must be treated aggressively with intravenous antibiotics and surgical intervention if necessary.

Epithelial ovarian cancer: An overview.

Ovarian cancer is the second most common gynecological cancer and the leading cause of death in the United States. In this article we review the diagnosis and current management of epithelial ovarian cancer which accounts for over 95 percent of the ovarian malignancies. We will present various theories about the potential origin of ovarian malignancies. We will discuss the genetic anomalies and syndromes that may cause ovarian cancers with emphasis on Breast cancer type 1/2 mutations. The pathology and pathogenesis of ovarian carcinoma will also be presented. Lastly, we provide a comprehensive overview of treatment strategies and staging of ovarian cancer, conclusions and future directions.

Using augmented reality as a clinical support tool to assist combat medics in the treatment of tension pneumothoraces.

This study was to extrapolate potential roles of augmented reality goggles as a clinical support tool assisting in the reduction of preventable causes of death on the battlefield. Our pilot study was designed to improve medic performance in accurately placing a large bore catheter to release tension pneumothorax (prehospital setting) while using augmented reality goggles. Thirty-four preclinical medical students recruited from Morehouse School of Medicine performed needle decompressions on human cadaver models after hearing a brief training lecture on tension pneumothorax management. Clinical vignettes identifying cadavers as having life-threatening tension pneumothoraces as a consequence of improvised explosive device attacks were used. Study group (n = 13) performed needle decompression using augmented reality goggles whereas the control group (n = 21) relied solely on memory from the lecture. The two groups were compared according to their ability to accurately complete the steps required to decompress a tension pneumothorax. The medical students using augmented reality goggle support were able to treat the tension pneumothorax on the human cadaver models more accurately than the students relying on their memory (p < 0.008). Although the augmented reality group required more time to complete the needle decompression intervention (p = 0.0684), this did not reach statistical significance.

Benefit of a Tiered-Trauma Activation System to Triage Dead-on-Arrival Patients.

INTRODUCTION: Although national guidelines have been published for the management of critically injured traumatic cardiopulmonary arrest (TCPA) patients, many hospital systems have not implemented in-hospital triage guidelines. The objective of this study was to determine if hospital resources could be preserved by implementation of an in-hospital tiered triage system for patients in TCPA with prolonged resuscitation who would likely be declared dead on arrival (DOA). METHOD: We conducted a retrospective analysis of 4,618 severely injured patients, admitted to our Level I trauma center from December 2000 to December 2008 for evaluation. All of the identified patients had sustained life-threatening penetrating and blunt injuries with pre-hospital TCPA. Patients who received cardiopulmonary resuscitation (CPR) for 10 minutes were assessed for survival rate, neurologic outcome, and charge-for-activation (COA) for our hospital trauma system. RESULTS: We evaluated 4,618 charts, which consisted of patients seen by the MSM trauma service from December 2001 through December 2008. We identified 140 patients with severe, life-threatening traumatic injuries, who sustained pre-hospital TCPA requiring prolonged CPR in the field and were brought to the emergency department (ED). Group I was comprised of 108 patients sustaining TCPA (53 blunt, 55 penetrating), who died after receiving < 45 minutes of ACLS after arrival. Group II, which consisted of 32 patients (25 blunt, 7 penetrating), had resuscitative efforts in the ED lasting > 45 minutes, but all ultimately died prior to discharge. Estimated hospital charge-for-activation for Group I was approximately $540,000, based on standard charges of $5000 per full-scale trauma system activation (TSA). CONCLUSION: Full-scale trauma system activation for patients sustaining greater than 10 minutes of prehospital TCPA in the field is futile and economically depleting.

The effect of video game "warm-up" on performance of laparoscopic surgery tasks.

BACKGROUND: Performing laparoscopic procedures requires special training and has been documented as a significant source of surgical errors. "Warming up" before performing a task has been shown to enhance performance. This study investigates whether surgeons benefit from "warming up" using select video games immediately before performing laparoscopic partial tasks and clinical tasks. METHODS: This study included 303 surgeons (249 men and 54 women). Participants were split into a control (n=180) and an experimental group (n=123). The experimental group played 3 previously validated video games for 6 minutes before task sessions. The Cobra Rope partial task and suturing exercises were performed immediately after the warm-up sessions. RESULTS: Surgeons who played video games prior to the Cobra Rope drill were significantly faster on their first attempt and across all 10 trials. The experimental and control groups were significantly different in their total suturing scores (t=2.28, df=288, P<.05). The overall Top Gun score showed that the experimental group performed marginally better overall. CONCLUSION: This study demonstrates that subjects completing "warming-up" sessions with select video games prior to performing laparoscopic partial and clinical tasks (intracorporeal suturing) were faster and had fewer errors than participants not engaging in "warm-up." More study is needed to determine whether this translates into superior procedural execution in the clinical setting.