Mortality and failure-to-rescue after esophagectomy in the procedure-targeted National Surgical Quality Improvement Program registry.

BACKGROUND: The association between procedural volume and esophagectomy outcomes has been established, but the relationship between higher levels of care and esophagectomy outcomes has not been explored. This study aims to investigate whether hospital participation in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) esophagectomy-targeted registry is associated with superior outcomes. METHODS: The 2016-2020 ACS NSQIP standard and esophagectomy-targeted registries were queried. Esophagectomy outcomes were analyzed overall and stratified by esophagectomy type (Ivor Lewis vs. transhiatal vs. 3-field McKeown). RESULTS: A total of 2181 and 5449 esophagectomy cases were identified in the standard and targeted databases (68% Ivor Lewis esophagectomy). The median age was 65 years and 80% were male. Preoperative characteristics were largely comparable. On univariate analysis, targeted hospitals were associated with lower mortality (2% vs. 4%, p < 0.01) and failure-to-rescue rates (11% vs. 17%, p < 0.01), higher likelihood of an optimal outcome (62% vs. 58%, p = 0.01), and shorter hospital stay (median 9 vs. 10 days, p < 0.01). On multivariable analysis, Ivor Lewis esophagectomy at targeted centers was associated with reduced odds of mortality [odds ratio (OR) 0.57 and 95% confidence intervals 0.35-0.90] and failure-to-rescue [OR 0.54 (0.33-0.90)] with no difference in serious morbidity or optimal outcome. There was no statistically significant difference in odds of mortality or failure to rescue in targeted versus standard centers when performing transhiatal or McKeown esophagectomy. CONCLUSIONS: Esophagectomy performed at hospitals participating in the targeted ACS NSQIP is associated with roughly half the risk of mortality compared to the standard registry. The factors underlying this relationship may be valuable in quality improvement.

Percutaneous cecostomy: 25-year two institution experience.

BACKGROUND: Reports of technical success, adverse events, and long-term outcome of percutaneous cecostomy in children are limited. OBJECTIVE: To characterize technical success, 30-day severe adverse events, and long-term outcome of percutaneous cecostomy at two centers. MATERIALS AND METHODS: A retrospective review of hospital course and long-term follow-up (through May 2022) of percutaneous cecostomy tubes placed May 1997 to August 2011 at two children's hospitals was used. Outcomes assessed included technical success (defined as successful tube placement into the colon allowing antegrade colonic enemas), length of stay, 30-day severe adverse events, surgery consults, surgical repair, VP shunt infection, ongoing flushes, tube removal, duration between maintenance tube exchanges, and deaths. RESULTS: A total of 215 procedures were performed in 208 patients (90 institution A, 125 institution B). Tubes were placed for neurogenic bowel (72.1%, n = 155) and functional constipation (27.9%, n = 60). Technical success was 98.1% (211/215) and did not differ between centers (p = 0.74). Surgical repair was required for bowel leakage in 5.1% (11/215) and VP shunt infection was managed in 2.1% (2/95). Compared to functional constipation, patients with neurogenic bowel had higher % tube remaining (65.3% [96/147] versus 25.9% [15/58], p < 0.001) and higher ongoing flushes at follow-up (42.2% [62/147] versus 12.1% [7/58], p < 0.001). Tube removal for dissatisfaction occurred in 15.6% [32/205] and did not differ between groups (p = 0.98). Eight deaths due to co-morbidity occurred after a median of 7.4 years (IQR 9.3) of tube access. CONCLUSION: Percutaneous cecostomy is technically successful in the vast majority of patients and provided durable access in most. Bowel leakage and VP shunt infection are uncommon, severe adverse events.

Higher Doses of Calcium Associated With Survival in Trauma Patients.

INTRODUCTION: Calcium is required for coagulation, cardiac output, and peripheral vascular resistance. Between 85% and 94% of trauma patients treated with massive blood transfusion develop hypocalcemia.1 The aim of this study is to evaluate the relationship between increased intravenous calcium administration during massive transfusion and improved survival of trauma patients. METHODS: We performed a retrospective analysis of trauma patients who received massive transfusion over a 2-y period. Doses of elemental calcium administered per unit of blood product transfused were calculated by calcium to blood product ratio (CBR). Chi-square test evaluated association between coagulopathy and 30-d mortality. Two-sample t-test evaluated association between CBR and coagulopathy. Bivariate regression analysis evaluated association between CBR and blood products transfused per patient. Multivariable logistic regression analysis, controlling for age, sex, coagulopathy, and Injury Severity Score evaluated the association between CBR and mortality. RESULTS: The study included 77 patients. Coagulopathy was associated with increased 30-d mortality (P < 0.05). Patients who survived had higher CBR than those who died (P < 0.05). CBR was associated with a significant reduction in total blood products transfused per patient (P < 0.05). CBR was not associated with coagulopathy (P = 0.24). Multivariable logistic regression analysis demonstrated that Injury Severity Score ≥16, coagulopathy and decreased CBR were significant predictors of mortality (P < 0.05). CBR above 50 mg was a predictor of survival (P < 0.05). CONCLUSIONS: Higher doses of calcium given per blood product transfused were associated with improved 30-d survival and decreased blood product transfusions.

A closed surgical intensive care unit organization improves cardiac surgical patient outcomes.

Background: Intensive care unit (ICU) organization is a critical factor in optimizing patient outcomes. ICU organization can be divided into "OPEN" (O) and "CLOSED" (C) models, where the specialist or intensivist, respectively, assumes the role of primary physician. Recent studies support improved outcomes in closed ICUs, however, most of the available data is centered on ICUs generally or on subspecialty surgical patients in the setting of a subspecialized surgical intensive care unit (SICU). We examined the impact of closing a general SICU on patient outcomes following cardiac and ascending aortic surgery. Methods: A retrospective cohort of patients following cardiac or ascending aortic surgery by median sternotomy was examined at a single academic medical center one year prior and one year after implementation of a closed SICU model. Patients were divided into "OPEN" (O; n=53) and "CLOSED" (C; n=73) cohorts. Results: Cohorts were comparable in terms of age, race, and number of comorbid conditions. A significant difference in male gender (O: 60.4% vs. C: 76.7%, P=0.049), multiple procedure performed (O: 13.21% vs. C: 35.62%, P=0.019), and hospital readmission rates was detected (O: 39.6% vs. C: 9.6%, P=0.0003). Using a linear regression model, a closed model SICU organization decreased SICU length of stay (LOS). Using a multivariate logistic regression, being treated in a closed ICU decreased a patient's likelihood of having an ICU LOS greater than 48 hours. Conclusions: Our study identified a decreased ICU LOS and hospital readmission in cardiac and ascending aortic patients in a closed general SICU despite increased procedure complexity. Further study is needed to clarify the effects on surgical complications and hospital charges.

An unexpected case of large cell neuroendocrine carcinoma of the colon: a case report.

Background: Patients presenting with large cell neuroendocrine carcinomas (LCNECs) comprise a small minority of total colon and rectal cancers (1-2%) with poor prognostic outcomes in lieu of late diagnosis and metastasis at the point of diagnosis. Case Description: We report a case presentation of a 69-year-old male presenting with diffuse, non-severe upper abdominal pain and a positive at-home colon cancer screening test. At the time of presentation, the patient was negative for constipation or blood in stool. The patient underwent a colonoscopy with biopsy results positive for LCNEC within the proximal ascending colon. A right hemicolectomy was performed with subsequent pathology indicating a poorly differentiated LCNEC with 4/18 positive nodes and final pathology showing stage IIIA (T3, N1, M0) with Ki-67 index at 70%. Post-operative intervention included two cycles of carboplatin and etoposide as well as routine follow-up for labs, imaging, and pharmacological management. Conclusions: LCNECs are highly aggressive with poor prognostic outcomes and high mortality rates on both 1- and 5-year survival scales. Prior studies and reports indicated a need for further research and data investigating treatment standardization for patients diagnosed with LCNECs. In lieu of this, this study provides a potential standardized treatment modality combining both European Neuroendocrine Tumor Society (ENETS) and North American Neuroendocrine Tumor Society (NANETS) consensus guidelines.

Weight-Based Dosing for Low-Molecular-Weight Heparin (Enoxaparin) Administration to Achieve Optimal VTE Prophylaxis in Trauma Patients.

INTRODUCTION: Patients admitted after traumatic injuries are at high risk for developing venous thromboembolism (VTE). Low-molecular-weight heparin (LMWH) is commonly used to prevent VTE in this patient population; however, the optimal dosing strategy has yet to be determined. To address this question, a fixed-dosing strategy of LMWH was compared to a weight-based dosing strategy of LMWH for VTE prophylaxis. METHODS: A retrospective, pre-post implementation cohort study compared a fixed vs a weight-based dosing strategy of LMWH for VTE prophylaxis. Patients admitted to our level 1 trauma center were included if they had an estimated glomerular filtration rate >30 mL/min/1.73 m2, received at least 3 doses of LMWH, and had an appropriately drawn anti-Xa level on their initial dosing regimen. Patients in the pre-cohort received 30 mg LMWH subcutaneously twice daily as the initial dosing regimen. Patients in the post-cohort received .5 mg/kg (max 60 mg) LMWH subcutaneously every 12 h as the initial dosing regimen. A goal anti-Xa of .2-.4 IU/mL was targeted for prophylaxis. RESULTS: There were 817 patients in the fixed-dosing group (FDG) and 874 patients in the weight-based dosing group (WBDG). In the FDG, 42.8% of the patients achieved the goal initial anti-Xa level, with 54.1% and 3.1% reaching sub- and supratherapeutic doses, respectively. In the WBDG, 66.5% of patients reached goal initial anti-Xa levels, with 23.5% and 10.1% at sub- and supratherapeutic levels. The distribution of dose ranges was significantly different between the dosing strategies (P-value <.001). There was no difference in the number of patients who received blood products (39.1% vs 41.7%. P-value = .299). CONCLUSIONS: In our study, weight-based dosing of LMWH yielded a significantly higher proportion of patients who achieved goal prophylactic anti-Xa levels than fixed-dosing of LMWH. Larger-scale studies are needed to assess the risk of VTE events and bleeding with these dosing strategies.

Readmissions After Traumatic Brain Injury in the Nationwide Readmissions Database.

INTRODUCTION: Readmissions after a traumatic brain injury (TBI) can have severe impacts on long-term health outcomes as well as rehabilitation. The aim of this descriptive study was to analyze the Nationwide Readmissions Database to determine possible risk factors associated with readmission for patients who previously sustained a TBI. METHODS: This retrospective study used data from the Nationwide Readmissions Database to explore gender, age, injury severity score, comorbidities, index admission hospital size, discharge disposition of the patient, and cause for readmission for adults admitted with a TBI. Multivariable logistic regression was used to assess likelihood of readmission. RESULTS: There was a readmission rate of 28.7% (n = 31,757) among the study population. The primary cause of readmission was either subsequent injury or sequelae of the original injury (n = 8825; 29%) followed by circulatory (n = 5894; 19%) and nervous system issues (n = 2904; 9%). There was a significantly higher risk of being readmitted in males (Female odds ratio: 0.87; confidence interval [0.851-0.922), older patients (65-79: 32.3%; > 80: 37.1%), patients with three or more comorbidities (≥ 3: 32.9%), or in patients discharged to a skilled nursing facility/intermediate care facility/rehab (SNF/ICF/Rehab odds ratio: 1.55; confidence interval [0.234-0.262]). CONCLUSIONS: This study demonstrates a large proportion of patients are readmitted after sustaining a TBI. A significant number of patients are readmitted for subsequent injuries, circulatory issues, nervous system problems, and infections. Although readmissions cannot be completely avoided, defining at-risk populations is the first step of understanding how to reduce readmissions.

Factors for which radiology residents choose fellowship.

PURPOSE: The objective of this study is to assess factors that influence radiology residents' decision to pursue fellowship. Historically a large majority of Diagnostic Radiology (DR) residents have pursued fellowship, but with changes in the job market and the Covid-19 pandemic, this study analyzes the current trends associated with radiology fellowship choice. MATERIALS AND METHODS: An anonymous 28-question survey was constructed based on literature review and pilot feedback from university radiology residents. The survey was distributed through APDR and to all program coordinators to be distributed to residents. Demographic information and questions related to fellowship choice were assessed. The survey was conducted through RedCap and consisted of multiple choice and sliding scale questions. RESULTS: 214 radiology residents responded, representing 4.6 % of US DR residents across 199 programs. The top fellowship choices included neuroradiology (20.5 %), musculoskeletal imaging (17.3 %), body imaging (16.8 %), and breast imaging (16.4 %). Most influential factors for fellowship selection were strong personal interest, enjoyable rotation, work hours, job security, and compensation. Least influential factors were research opportunities and specific group practice. CONCLUSION: The decision to pursue fellowship remains almost unanimous among US DR residents. Strong personal interest, enjoyable rotations, and favorable work hours were rated as the most important factors in the decision to pursue fellowship. Neuroradiology, musculoskeletal, and body imaging remained the most popular specialties, with a notable increase in interest in breast radiology compared to literature. To attract prospective fellows, residency and fellowship programs should emphasize aforementioned factors and offer more early exposure to subspecialties during residency.

Review of the demographic and educational profiles of abdominal imaging fellowship program directors in the United States.

PURPOSE: To evaluate demographics, academic backgrounds, and scholarly activities of Program Directors (PDs) in Abdominal Imaging Fellowships in the United States (US), emphasizing gender representation, international origins, and academic milestones. METHODS: A list of Fellowships in Abdominal Imaging programs in the US was obtained from the Society of Abdominal Radiology. The search was expanded using the Fellowship and Residency Electronic Interactive Database. Data for PDs were sourced from program websites, Healthgrades, Doximity, and Elsevier's Scopus. Metrics such as age, gender, education, academic rank, additional qualifications, prior leadership roles, publications, and h-indices were analyzed using R software. A two-tailed unpaired t-test was used to calculate the difference in means of scholarly activity between male and female PDs. RESULTS: 113 programs were identified: South (36.28%), Northeast (25.66%), Mid-West (20.35%), West (17.69%). Of 107 PDs, 54% male, 41% female, and average age 48 ± 9.4 years. 66.6% were US graduates, 29.2% were international graduates. Most were Assistant Professors (36.28%). 19.46% had degrees like M.P.H. or M.B.A. 45% had prior leadership roles. Average year of residency graduation was 2007. Mean publication count was 54.16, and mean h-index was 14.663. Male PDs had higher publication counts and h-indices than female PDs (p= 0.009 and p= 0.0019 respectively). CONCLUSION: In Abdominal Imaging Fellowship programs in the US, there is an increasing representation of females in Program Director roles. However, research led by female PDs remains less prevalent. The field of Abdominal Imaging values contributions from international graduates and insights from Assistant Professors.

Complications and failure-to-rescue after pancreatectomy and hospital participation in the targeted American College of Surgeons National Surgical Quality Improvement Program registry.

BACKGROUND: More than 700 hospitals participate in the American College of Surgeons National Surgical Quality Improvement Program, but most pancreatectomies are performed in 165 centers participating in the pancreas procedure-targeted registry. We hypothesized that these hospitals ("targeted hospitals") might provide more specialized care than those not participating ("standard hospitals"). METHODS: The 2014 to 2019 pancreas-targeted and standard American College of Surgeons National Surgical Quality Improvement Program registry were reviewed regarding patient demographics, comorbidities, and perioperative outcomes using standard univariate and multivariable logistic regression analyses. Primary outcomes included 30-day mortality and serious morbidity. RESULTS: The registry included 30,357 pancreatoduodenectomies (80% in targeted hospitals) and 14,800 distal pancreatectomies (76% in targeted hospitals). Preoperative and intraoperative characteristics of patients treated at targeted versus standard hospitals were comparable. On multivariable analysis, pancreatoduodenectomies performed at targeted hospitals were associated with a 39% decrease in 30-day mortality (odds ratio, 0.61; 95% confidence interval, 0.50-0.75), 17% decrease in serious morbidity (odds ratio, 0.83; 95% confidence interval, 0.77-0.89), and 41% decrease in failure-to-rescue (odds ratio, 0.59; 95% confidence interval, 0.47-0.74). These differences did not apply to distal pancreatectomies. Participation in the targeted registry was associated with higher rates of optimal surgery for both pancreatoduodenectomy (odds ratio, 1.33; 95% confidence interval, 1.25-1.41) and distal pancreatectomy (odds ratio, 1.17; 95% confidence interval, 1.06-1.30). CONCLUSION: Mortality and failure-to-rescue rates after pancreatoduodenectomy in targeted hospitals were nearly half of rates in standard American College of Surgeons National Surgical Quality Improvement Program hospitals. Further research should delineate factors underlying this effect and highlight opportunities for improvement.

Weight-Based Dosing for Venous Thromboembolism Prophylaxis in Spinal Trauma Patients Appears Safe.

INTRODUCTION: Venous thromboembolism (VTE) is a substantial cause of morbidity and mortality in trauma patients. VTE prophylaxis (VTEP) initiation is often delayed in certain patients due to the perceived risk of bleeding complications. Our VTEP guideline was changed from fixed-dosing to a weight-based dosing strategy using enoxaparin in June 2019. We investigated the rate of postoperative bleeding complications with a weight-based and a standard dosing protocol in traumatic spine injury patients requiring surgical stabilization. METHODS: A retrospective pre-post cohort study using an institutional trauma database was conducted, comparing bleeding complications between fixed and weight-based VTEP protocols. Patients undergoing surgical stabilization of a spine injury were included. The preintervention cohort received fixed-dose thromboprophylaxis (30 mg twice daily or 40 mg daily); the postcohort received weight-based thromboprophylaxis (0.5 mg/kg q12 h with anti-factor Xa monitoring). All patients received VTEP 24-48 h after surgery. International Classification of Diseases codes were used to identify bleeding complications. RESULTS: There were 68 patients in the pregroup and 68 in the postgroup with comparable demographics. Incidence of bleeding complications in the pre- and postgroups were 2.94% and 0% respectively. CONCLUSIONS: VTEP initiated 24-48 h after surgical stabilization of a spine fracture using a weight-based dosing strategy and has a similar rate of bleeding complications as a standard dose protocol. Our study is limited by the low overall incidence of bleeding complications and small sample size. These findings could be validated by a larger multicenter trial.

Broadening the Understanding of Medical Students' Discussion of Radiology Online: A Social Listening Study of Reddit.

Reddit.com contains one of the largest online social forums for medical students, the 'r/medicalschool' subreddit. The platform provides an opportunity to share news and discuss a variety of topics including specialty choice and residency applications. In this study we analyze posts on the subreddit r/medicalschool with the aim of understanding how medical students perceive radiology as a career and what factors influence their decision to pursue radiology. Reddit posts to were collected from the r/medicalschool subreddit (2009-2022) and a randomized sample of the corpus was labeled to yield 2000 posts that discussed radiology as career and 1542 posts not discussing radiology. Sentiment analysis of the labeled corpus was conducted using the SiEBRT RoBERTa transformer sentiment pipeline, a machine trained English language text analyzer. Student's t-test was used to compare sentiment of posts discussing radiology to nonradiology posts by career keywords. Posts discussing radiology as a career had an overall positive sentiment but were lower than nonradiology posts' sentiment (p<.001). Key words associated with a positive sentiment score were "procedure", "lifestyle", "income", "fit", "personality", "anatomy", "tech", "physics", "research," and "match." Negative sentiment score included key words "AI", "burnout", "culture", "job market", "midlevel", "sue", "teleradiology." "Procedures" had the most positive sentiment score, while "AI" had the most negative score. Our study highlights aspects of radiology as a career that are discussed positively and negatively on Reddit. These posts are read by medical students around the world and may influence their choice of specialty.

Establishing a pediatric interventional radiology inpatient consult service.

OBJECTIVE: To delineate pediatric interventional radiology (IR) inpatient consult growth and resulting collections after implementation of a pediatric IR consult service. METHODS: An inpatient IR consult process was created at a single academic children's hospital in October 2019. IR consult note templates were created in Epic (Epic Systems Corporation, Verona, Wisconsin) and utilized by 4 IR physicians. Automatic charge generation was linked to differing levels of evaluation and management (E&M) service relating to current procedural terminology (CPT) inpatient consult codes 99251-99255. The children's hospital informatics division identified IR consult notes entered from the implementation of the consult service: October 2019 to January 2022. The university radiology department billing office provided IR service E&M charge, payment, and relative value units (RVU) information during this study period. A chart review was performed to determine the IR procedure conversion rate. Mann-Whitney and a two-sample t-test statistical analyses compared use of the 25-modifier, monthly consult growth and monthly payment growth. P-value < 0.05 was considered statistically significant.  RESULTS: Within this 27-month period, a total of 2153 inpatient IR consults were performed during 1757 Epic hospital encounters; monthly consult peak was reached 5 months into the study period. Consult level breakdown by CPT codes: 99251-8.7%, 99252-81.7%, and 99253-8.8%. 69.7% of IR consults had consult-specific billing with payments in 96.4% resulting in $143,976 new revenue. From 2020 to 2021, IR consult volume trended upward by 13.4% (P =0.069), and consult-specific payments increased by 84.1% (P<0.001). IR consult procedure conversion rate was 96.5%. CONCLUSION: An inpatient pediatric IR consult service was quickly established and maintained by four physicians over a 27-month study period. Annual IR consult volume trended upward and consult-specific payments increased, resulting in previously uncaptured IR service revenue.

Deep vein thrombosis causing abdominal wall varicosities.

Deep venous thrombosis (DVT) is a common medical finding occurring in ~25% of hospitalized patients with roughly half of these patients experiencing post-thrombotic complications [Baldwin, Moore, Rudarakanchana, Gohel, Davies (Post-thrombotic syndrome: a clinical review. J Thromb Haemost 2013;11:795-805.)]. There are many associated complications of DVTs, including pulmonary embolism and lower extremity swelling; however, the occurrence of abdominal wall varicosities with DVT's is rare [Baldwin, Moore, Rudarakanchana, Gohel, Davies (Post-thrombotic syndrome: a clinical review. J Thromb Haemost 2013;11:795-805.)]. The purpose of this case study is to rare presentation of abdominal vein varicosities as manifestation of DVT.

COVID-19 Monoclonal Antibody Administration Linked to Drop in Blood Pressure: A Retrospective Cohort Study.

This study reports on hemodynamic changes observed during monoclonal antibody (mAb) administration for patients with severe acute respiratory distress syndrome-coronavirus-2. Findings from this study may have implications for patient safety. Hemodynamic data from 705 patients who received subcutaneous or intravenous mAb therapy during February 1, 2021-September 30, 2021 in clinics in Arkansas, USA were reviewed. Descriptive statistics and paired t-tests were used to assess blood pressure before and after treatment. Results showed 386 (54.7%) patients experienced a drop in systolic blood pressure (SBP) or diastolic blood pressure (DBP) >5 mmHg. The average drop in SBP was 9.2 mmHg for those patients. Two hundred and eighty-one (39.9%) patients experienced a drop in SBP of >10 mmHg with an average drop in SBP of 12.0 mmHg. The Emergency Use Authorization for mAb does not list hypotension as a contraindication for treatment. Our findings suggest mAb therapy should be administered in an environment where vitals are monitored.

Utilizing procalcitonin in a clinical setting to help differentiate between aspiration pneumonia and aspiration pneumonitis.

OBJECTIVE: Aspiration can lead to complications such as aspiration pneumonia (ASPNA) or aspiration pneumonitis. Use of procalcitonin (PCT) assays has been supported to help differentiate between bacterial and nonbacterial etiologies for infection. We hypothesize PCT levels will differ significantly in patients with ASPNA versus aspiration pneumonitis. METHODS: This study retrospectively analyzed patients with an ICD-10 diagnosis of ASPNA or aspiration pneumonitis from September 2017 to September 2019. 228 patients met criteria and were divided into two cohorts: aspiration pneumonitis (45 patients) or ASPNA (183 patients). Initial and 48-hour PCTs were assessed. RESULTS: The aspiration pneumonitis cohort had a higher percentage of patients with normal initial PCT levels than the ASPNA cohort (86.7% vs 38.8%; P < 0.0001). CONCLUSION: This study suggests PCT could be a useful tool to help differentiate between ASPNA and aspiration pneumonitis. We postulate utilizing PCT levels alongside current diagnostic criteria would allow for more appropriate treatment and improved antibiotic stewardship.

Incidence of Red Cell Antibody Formation Following Massive Transfusion Protocol: Experience of a Single Institution.

BACKGROUND: Injured patients in hemorrhagic shock have a survival benefit with massive transfusion protocol (MTP). While there are many published studies on the transfusion management of massively bleeding patients, the risk of alloimmunization in patients that have received products during an MTP activation is relatively unknown. Therefore, we sought to determine the frequency of new antibody formation in MTP patients that received blood products from an uncrossmatched megapack. MATERIALS AND METHODS: We conducted a retrospective data review of patients who underwent an MTP activation for trauma resuscitation between May 2014 and July 2020. Data were collected from patients who met the following criteria: MTP was activated, the patients received at least one unit of packed red blood cells, one unit of fresh frozen plasma, one unit of platelets, and had a repeat type and screen within 6 weeks of transfusion. These inclusion criteria resulted in 28 patients over the 6-year timeframe. RESULTS: Overall, the risk of alloimmunization secondary to MTP is 3.6% in our trauma patient population. The newly developed antibodies post-MTP are considered clinically significant, meaning they can cause hemolysis if exposed to donor red blood cells containing those antigens. DISCUSSION: Blood products should be given preferentially over crystalloids to acutely bleeding patients to prevent ischemic injury during an MTP activation despite the risk of alloimmunization. In our single-institution study, the alloimmunization rate in massive transfusions where patients receive uncrossmatched red blood cells is similar to those receiving crossmatched red blood cells.

Closed Collaborative Surgical Intensive Care Unit Modeling and Its Association With Trauma Patient Outcomes.

INTRODUCTION: The optimization of intensive care unit (ICU) care impacts clinical outcomes and resource utilization. In 2017, our surgical ICU (SICU) adopted a "closed-collaborative" model. The aim of this study is to compare patient outcomes in the closed-collaborative model versus the previous open model in a cohort of trauma surgical patients admitted to our adult level 1 trauma center. METHODS: A retrospective review of trauma patients in the SICU from August 1, 2015 to July 31, 2019 was performed. Patients were divided into those admitted prior to August 1, 2017 (the "open" cohort) and those admitted after August 1, 2017 (the "closed-collaborative" cohort). Demographic variables and clinical outcomes were analyzed. Trauma severity was assessed using injury severity score (ISS). RESULTS: We identified 1669 patients (O: 895; C: 774). While no differences in demographics were observed, the closed-collaborative cohort had a higher overall ISS (O: 21.5 ± 12.14; C: 25.10 ± 2.72; P < 0.0001). There were no significant differences between the two cohorts in the incidence of strokes (O: 1.90%; C: 2.58%, P = 0.3435), pulmonary embolism (O: 0.78%; C: 0.65%; P = 0.7427), sepsis (O: 5.25%; C: 7.49%; P = 0.0599), median ICU charges (O: $7784.50; C: $8986.53; P = 0.5286), mortality (O: 11.40%; C: 13.18%; P = 0.2678), or ICU length of stay (LOS) (O: 4.85 ± 6.23; C: 4.37 ± 4.94; P = 0.0795). CONCLUSIONS: Patients in the closed-collaborative cohort had similar clinical outcomes despite having a sicker cohort of patients. We hypothesize that the closed-collaborative ICU model was able to maintain equivalent outcomes due to the dedicated multidisciplinary critical care team caring for these patients. Further research is warranted to determine the optimal model of ICU care for trauma patients.

Morbidity of colectomy during pancreatoduodenectomy: An analysis of the pancreas-targeted American College of Surgeons National Surgical Quality Improvement Program Registry.

BACKGROUND: Pancreatoduodenectomy is a complex operation with considerable morbidity and mortality. Locally advanced tumors may require concurrent colectomy. We hypothesized that a concurrent colectomy increases the risk associated with pancreatoduodenectomy. METHODS: This retrospective review of the 2014-2019 pancreas-targeted American College of Surgeons National Surgical Quality Improvement Program registry classified operations as pancreatoduodenectomy (PD) versus pancreatoduodenectomy/colectomy (PD+C). The two groups were compared with respect to demographics, comorbidities, disease characteristics, intraoperative variables, and postoperative outcomes. Main effect models were developed to examine the effect of concurrent colectomy on outcomes after adjusting for potential confounders. RESULTS: Of 24 421 pancreatoduodenectomies, 430 (1.8%) involved concurrent colectomy. PD + C patients had less comorbidities (obesity 19% vs. 27%, hypertension 43% vs. 53%, diabetes 20% vs. 26%) and were associated with malignant diagnosis (94% vs. 83%), vascular resection (28% vs. 18%), and longer operative time (median 6.9 vs. 6 h). On multivariable analysis, concurrent colectomy was independently associated with serious morbidity (adjusted odds ratio [OR] 2.62, 95% confidence interval [CI]: 1.94-3.54) but not mortality (OR 1.44 [0.63-3.31]). CONCLUSIONS: Concurrent colectomy at the time of pancreatoduodenectomy significantly increased the odds of serious morbidity but did not affect mortality. This should be considered in operative planning, preoperative counseling, and sequencing of cancer-directed treatments.

Prophylactic Antibiotics in Patients with Traumatic Pneumocephalus or Cerebrospinal Fluid Leak.

INTRODUCTION: Pneumocephalus and cerebrospinal fluid (CSF) leaks are uncommon after trauma, but they expose the sterile CSF to environmental pathogens and create theoretical risk of central nervous system infection (CNSI). Prophylactic antibiotics are commonly given to these patients, but there is a paucity of evidence to guide this practice. We aim to quantify the incidences of these entities and analyze the efficacy of prophylactic antibiotics in preventing CNSIs. METHODS: A retrospective cohort study was conducted using our institutional trauma registry. All patients admitted from January 2014 to July 2020 with traumatic pneumocephalus (TP) or basilar skull fracture with CSF leak (BSF-CSF) were included. ICD-9 and ICD-10 codes were used to identify CNSIs. CNSI rates among defined prophylactic antibiotic regimens, no antibiotics, and other antibiotic regimens were evaluated. ANOVA was used to analyze differences between the groups. RESULTS: 365 patients met inclusion criteria: 360 with TP; 5 with BSF-CSF. 1.1% (4/365) of patients developed CNSI, all with isolated traumatic pneumocephalus. 1.4% of patients (1/72) without antibiotics; 1.2% (3/249) receiving IV antibiotics outside of a defined regimen; and 1.1% (1/88) on a designated prophylactic regimen developed CNSIs. ANOVA indicated the incidence of CNSI was not significantly different among patients who received antibiotics or not, regardless of the regimen (p-value 0.958). CONCLUSION: TP and BSF-CSF are rare diagnoses among trauma patients. The rate of CNSI is marginal and antibiotics do not appear to confer a protective advantage. A larger trial is needed to elucidate the true effect of antibiotics on preventing CNSIs in patients with these uncommon diagnoses.