The Use and Impact of a Decision Support Tool for Appendicitis Treatment.

OBJECTIVE: Since introducing new and alternative treatment options may increase decisional conflict, we aimed to describe the use of the decision support tool (DST) and its impact on treatment preference and decisional conflict. SUMMARY BACKGROUND DATA: For the treatment of appendicitis, antibiotics are an effective alternative to appendectomy, with both approaches associated with a different set of risks (e.g., recurrence vs surgical complications) and benefits (e.g., more rapid return to work vs decreased chance of readmission). Patients often have limited knowledge of these treatment options and decision support tools that include video-based educational materials and questions to elicit patient preferences about outcomes may be helpful. Concurrent to the Comparing Outcomes of Drugs and Appendectomy (CODA) trial, our group developed a DST for appendicitis treatment (www.appyornot.org). METHODS: A retrospective cohort including people who self-reported current appendicitis and used the AppyOrNot DST between 2021-2023. Treatment preferences before- and after- use of the DST, demographic information, and Ottawa Decisional Conflict Scale (DCS) were reported after completing the DST. RESULTS: 8,243 people from 66 countries and all 50 US states accessed the DST. Before the DST, 14% had a strong preference for antibiotics and 31% for appendectomy, with 55% undecided. After using the DST, the proportion in the undecided category decreased to 49% (P<0.0001). 52% of those who completed the Ottawa Decisional Conflict Score (DCS) (n=356) reported the lowest level of decisional conflict (<25) after using the DST; 43% had a DCS score of 25-50, 5.1% had a DCS score of >50 and 2.5% had and DCS score of >75. CONCLUSION: The publicly available DST appyornot.org reduced the proportion that was undecided about which treatment they favored and had a modest influence on those with strong treatment preferences. Decisional conflict was not common after use. The use of this DST is now a component of a nationwide implementation program aimed at improving the way surgeons share information about appendicitis treatment options. If its use can be successfully implemented, this may be a model for improving communication about treatment for patients experiencing emergency health conditions.

Prehospital Trauma Care.

Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.

Increasing Injury Intensity among 6,500 Violent Deaths in the State of Maryland.

BACKGROUND: Anecdotal evidence strongly suggests there has been a rise in violent crimes. This study sought to examine trends in injury characteristics of homicide victims in Maryland. We hypothesized that there would be an increase in the severity of wound characteristics. STUDY DESIGN: The Office of the Chief Medical Examiner is a statewide agency designated by law to investigate all homicides, suicides, or unusual or suspicious circumstances. Using individual autopsy reports, we collected data among all homicides from 2005 to 2017, categorizing them into 3 time periods: 2005 to 2008 (early), 2009 to 2013 (mid), and 2014 to 2017 (late). Primary outcomes included the number of gunshots, stabs, and fractures from assaults. High-violence intensity outcomes included victims having 10 or more gunshots, 5 or more stabs, or 5 or more fractures from assaults. RESULTS: Of 6,500 homicides (annual range 403 to 589), the majority were from firearms (75%), followed by stabbings (14%) and blunt assaults (10%). Most homicide victims died in the hospital (60%). The average number of gunshots per victim was 3.9 (range 1 to 54), stabs per victim was 9.4 (range 1 to 563), and fractures from assaults per victim was 3.7 (range 0 to 31). The proportion of firearm victims with at least 10 gunshots nearly doubled from 5.7% in the early period to 10% (p < 0.01) in the late period. Similarly, the proportion with 5 or more stabbings increased from 39% to 50% (p = 0.02) and assault homicides with 5 or more fractures increased from 24% to 38% (p < 0.01). CONCLUSIONS: In Maryland, the intensity of violence increased across all major mechanisms of homicide. Further follow-up studies are needed to elucidate the root causes underlying this escalating trend.

Contemporary Management and Outcomes of Injuries to the Inferior Vena Cava: A Prospective Multicenter Trial From PROspective Observational Vascular Injury Treatment.

INTRODUCTION: Injuries to the inferior vena cava (IVC), while uncommon, have a high mortality despite modern advances. The goal of this study is to describe the diagnosis and management in the largest available prospective data set of vascular injuries across anatomic levels of IVC injury. METHODS: The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November 2013 to January 2019. Demographics, diagnostic modalities, injury patterns, and management strategies were recorded and analyzed. Comparisons between anatomic levels were made using non-parametric Wilcoxon rank-sum statistics. RESULTS: 140 patients from 19 institutions were identified; median age was 30 years old (IQR 23-41), 75% were male, and 62% had penetrating mechanism. The suprarenal IVC group was associated with blunt mechanism (53% vs 32%, P = .02), had lower admission systolic blood pressure, pH, Glasgow Coma Scale (GCS), and higher ISS and thorax and abdomen AIS than the infrarenal injury group. Injuries were managed with open repair (70%) and ligation (30% overall; infrarenal 37% vs suprarenal 13%, P = .01). Endovascular therapy was used in 2% of cases. Overall mortality was 42% (infrarenal 33% vs suprarenal 66%, P<.001). Among survivors, there was no difference in first 24-hour PRBC transfusion requirement, or hospital or ICU length of stay. CONCLUSIONS: Current PROOVIT registry data demonstrate continued use of ligation extending to the suprarenal IVC, limited adoption of endovascular management, and no dramatic increase in overall survival compared to previously published studies. Survival is likely related to IVC injury location and total injury burden.

Urology Consult: Association with Renal Trauma Imaging and Intervention.

OBJECTIVE: To describe rates of urology consultation following renal trauma and assess subsequent impact on imaging and intervention. Renal trauma may be initially managed by either trauma or urologic surgeons alone or collaboratively. Differences in management between the specialties are not well studied. METHODS: We conducted an IRB-approved retrospective review of patients at a Level I trauma center sustaining renal trauma between 2014 and 2021. Demographic, injury, radiologic, and intervention variables were extracted. Frequencies and medians were compared using chi-squared and Fischer's exact tests or Mann-Whitney U tests, respectively. Analyses were performed using STATA with P <.05 considered significant. RESULTS: From 2014 to 2021, 118 patients with median age 29 (IQR 22-41) sustained renal trauma. Urology was consulted in 18 (15.3%) cases. Demographic and injury characteristics were similar between the 2 groups. AAST renal injury grade was transcribed in the initial radiologic reports for 49 (41.5%) of patients. Those in the urology consult group were more likely to receive delayed contrast imaging during their admission (50.0% vs 17.0%, P <.01). Among those with high-grade injuries, those with urology consult were less likely to undergo nephrectomy (36.4% vs 78.8%, P = .02). CONCLUSION: We observed differences in imaging patterns between renal trauma patients who are managed primarily by trauma surgery versus urology. However, the impact of these differences in imaging remains to be elucidated. Among patients with high-grade renal trauma, urology consult was associated with decreased rate of nephrectomy, emphasizing the feasibility of renal salvage in a multidisciplinary trauma setting.

Opioid and Multimodal Analgesia Use Following Urological Trauma.

OBJECTIVE: To examine opioid use following Urological trauma. Increased opioid use is associated with inferior outcomes and risk of dependence, particularly in vulnerable populations. In contrast, multimodal analgesia following trauma allows decreased pain and readmission. Currently there is a paucity of data describing opioid usage following urological trauma. The purpose of this study was to assess utilization of opioids and multimodal pain regimens following urologic trauma. METHODS: We retrospectively examined 116 patients hospitalized following urologic trauma from 2016-2021. Inpatient and discharge utilization of opioids, multimodal analgesia and length of stay were stratified by affected organ. Analyses were performed in STATA with p<0.05 reaching significance. RESULTS: 116 patients were assessed; 84 (72.4%) required surgery. In the first 10 days, bladder injuries incurred higher mean and median OMEQ than other urological injuries. In nearly all groups, OMEQ prescribed at discharge is less than average inpatient OMEQ. Eighty-six (74.1%) patients received at least 2 different opioid medications while inpatient. Those with a history of opioid use received a significantly higher OMEQ dose per day (p<0.001). There were no significant differences between opioid prescribing patterns or average OMEQ dosages prescribed at discharge between those patients managed either surgically or non-operatively. Only 24 (20.7%) patients met the criteria for utilization of multimodal analgesia. CONCLUSION: Multimodal analgesia is severely underutilized following urological trauma. Combined with the development of opioid tolerance over long hospital stays, this creates an avenue for opioid misuse following discharge and provides an opportunity for improvement.

A Rare Case of Subcutaneous Insulin Resistance Presumed to be due to Paraneoplastic Process in Pancreatic Adenocarcinoma.

OBJECTIVE: We describe a rare case of profound subcutaneous insulin resistance (SIR) presumed due to a paraneoplastic process caused by pancreatic adenocarcinoma that improved with intravenous insulin and tumor resection. METHODS: An 80-year-old man with previously well-controlled type 2 diabetes mellitus had worsening glycemic control (hemoglobin A1C increase of 6.5% to 8.6% over 4 months) following a recent diagnosis of pancreatic adenocarcinoma. His blood glucose was uncontrolled at 600 mg/dL despite rapid up-titration of a subcutaneous basal-bolus insulin regimen totaling 1000 units/d. Extensive evaluation of insulin resistance including insulin antibodies and anti-insulin receptor antibodies was negative. Due to clinical deterioration, the patient underwent pancreaticoduodenectomy before the completion of neoadjuvant chemotherapy. The patient received intravenous insulin before surgery, which resulted in rapid improvement in glycemic control. The patient's blood glucose normalized, and he was maintained on metformin monotherapy following pancreaticoduodenectomy. RESULTS: This patient had evidence of SIR in the setting of pancreatic adenocarcinoma. SIR was likely a paraneoplastic process as glycemic control improved after tumor resection. Interestingly, the patient did not have hyperinsulinemia but rather evidence of ß-cell dysfunction, which highlights the possibility of exogenous insulin resistance. CONCLUSION: Paraneoplastic processes due to pancreatic adenocarcinoma can cause SIR, marked by profound hyperglycemia and deteriorating functional status. It is, therefore important to recognize this rare syndrome and appropriately escalate to a higher level of care and consider proceeding with tumor resection.

Meet your surgical team: The impact of a resident-led quality improvement project on patient satisfaction.

BACKGROUND: Patients often have an incomplete understanding of the levels of training and roles of the various surgical providers in teaching hospitals, leading to patient confusion and dissatisfaction. METHODS: Pre-intervention discharge surveys were administered to gastrointestinal surgery inpatients (10/2016-02/2017) to evaluate sentiments regarding their surgical team. During the intervention period (02/2017-05/2017), patients at admission received "facesheets" containing team member profiles, photos, training level, and roles. These patients were evaluated using the survey, and pre- and post-intervention scores compared. RESULTS: 153 pre- and 100 post-intervention surveys were collected. There was a significant increase in patients reporting it was important to know the surgical team members and that they knew team member roles (p ≤ 0.05). Scores in every domain of the satisfaction survey improved in the post-intervention period, although not reaching statistical significance. CONCLUSIONS: Improving how patients perceive their interactions with their surgical team has implications on patient satisfaction and hospital quality metrics.

Nationwide trends in mortality following penetrating trauma: Are we up for the challenge?

BACKGROUND: Despite a focus on improved prehospital care, penetrating injuries contribute substantially to trauma mortality in the United States. We therefore analyzed contemporary trends in prehospital mortality from penetrating trauma in the past decade. METHODS: We identified patients in the The National Trauma Data Bank from 2007 to 2010 ("early period") and 2011 to 2014 ("late period") with gunshot wounds (GSW) and stab wounds (SW), who were treated at hospitals that recorded dead-on-arrival statistics. Multivariable logistic regressions assessed differences in body locations of trauma, prehospital mortality, and in-hospital mortality between the early and late periods. Models accounted for hospital clusters and adjusted for age, pulse, hypotension, New Injury Severity Score, Glasgow Coma Scale, and number of injured body parts. RESULTS: From 2007 to 2014, 437,398 patients experienced penetrating traumas, with equal distributions of GSW and SW. There were unadjusted differences in prehospital mortality (GSW: early, 2.0% vs. late, 4.9%; SW: early, 0.2% vs. late, 1.1%) and in-hospital mortality (GSW: early, 13.8% vs. late, 9.5%; SW: early, 1.8% vs. late, 1.0%) by both mechanisms. After adjustment, patients in the late period relative to those in the early period had significantly higher odds of prehospital death (GSWs: adjusted odds ratio [aOR], 4.54; 95% confidence interval [CI], 3.31-6.22; SWs: aOR, 8.98; 95% CI, 5.50-14.67) and lower odds of in-hospital death (GSWs: aOR, 0.85; 95% CI, 0.80-0.90; SWs: aOR, 0.81; 95% CI, 0.71-0.92). Sensitivity analyses assessing GSWs and SWs by locations of body injury found similar results. Additionally, patients in the late period were more likely to experience penetrating injuries to the face, spine, and lower extremities. CONCLUSION: In the United States, the prevalence of penetrating traumas remains a nationwide burden. The odds of prehospital mortality has increased over fourfold for GSWs and almost ninefold for SWs. Examining violence intensity, along with improvements in hospital care and data collection, may explain these findings. LEVEL OF EVIDENCE: Prognostic and epidemiological, level IV.

Facility disparities in reporting comorbidities to the National Trauma Data Bank.

BACKGROUND: The National Trauma Data Bank (NTDB) includes patient comorbidities. This study evaluates factors of trauma centers associated with higher rates of missing comorbidity data. METHODS: Proportions of missing comorbidity data from facilities in the NTDB from 2011 to 2014 were evaluated for associations with facility characteristics. Proportional impact analysis was performed to identify potential policy targets. RESULTS: Of 919 included facilities, 85% reported comorbidity data in 95% or more cases; only 31.3% were missing no data. Missing rates were significantly different based on most facility categories, but independently associated only with hospital size, region, and trauma center level. Only 15% of centers were responsible for over 80% of cases missing data. CONCLUSIONS: There is significant nonrandom variation in reporting trauma patient comorbidities to the NTDB. Missing data needs to be recognized and considered in studies of trauma comorbidities. Targeted intervention may improve data quality.

Jejunal Carcinoid Tumors Presenting as Small Bowel Obstruction.

Carcinoid tumors are the most common form of gut neuroendocrine tumors, however, they rarely present with small bowel obstruction. We present a case of a 65-year-old woman without prior abdominal operations who presented with symptoms of small bowel obstruction. Computed tomography (CT) showed multiple air fluid levels and a transition point in the left mesentery with two soft tissue densities at the same level. The patient was taken to the operating room for surgical exploration, which showed two intramural masses in the mid and distal jejunum, which surgical pathology showed to be stage IIIB carcinoid tumor.

Spontaneous seromuscular laceration of the sigmoid colon: a case report.

Injury to bowel can result in high morbidity and death. Bowel injuries typically occur after external trauma to the abdomen. Bowel injury in the absence of external trauma is rare. Here, we report a 36-year-old male presenting with a sigmoid colon laceration likely due to long-standing constipation.