Is language a barrier in the management of acute appendicitis?

BACKGROUND: Language preference is a contributing factor for prolonged time from symptom onset to appendectomy within pediatrics, but is poorly characterized in adults. We aimed to investigate associations between language barriers and delays in assessment and treatment for adults with acute appendicitis. METHODS: In a multiethnic community, patients aged ≥18 years old who underwent appendectomy were identified between January 2017 and August 2022 at a single institution. Negative binomial regression was used to compare interval wait times to imaging, medication administration, and surgical evaluation between patients with limited English proficiency and those who are English proficient. RESULTS: Of the 1469 patients included, 48% (n = 699) were with limited English proficiency. Average age was higher for patients with limited English proficiency (45 vs 36, P < .001). Most of them were Asian (54%) and without private insurance (65%, P < .001). Symptom duration, incidence of septic shock, and date/time of presentation to the emergency department were similar. Patients with limited English proficiency presented more frequently with gangrenous appendicitis (20% vs 15%, P = .013) but not perforated (23% vs 20%, P = .065). They experienced longer wait times for surgical evaluation (376 vs 348 min, incidence rate ratio [IRR], 1.08; P = .002) but similar times for imaging, and medications administered. After controlling for demographics, triage acuity, and hospital factors, significantly longer wait times for surgical evaluation persisted (IRR adjusted, 1.07; P = .038). There was no significant difference in hospital length-of-stay, postoperative infection, or 30-day readmission rate. CONCLUSION: Adult patients with limited English proficiency may experience longer wait times for surgical evaluation for acute appendicitis, but this may not result in clinically significant delays in the initiation of treatment.

Prehospital Assaults Against Asian Americans, Native Hawaiians, and Pacific Islanders During COVID-19.

INTRODUCTION: Anti-Asian sentiment increased when the SARS-CoV-2 virus reached the United States in 2020. Trends in national assaults occurring during the COVID-19 pandemic in the Asian American, Native Hawaiian, and Pacific Islander (AANHPI) community were evaluated. METHODS: Patients treated for assaults by emergency medical services between January 2019 and December 2021 were extracted from ImageTrend Collaborate, a national database. Multivariable logistic regression models, adjusting for age, sex, and urbanicity, were used to compare assault rates overall and in the AANHPI population. RESULTS: There were 84,825 assaults (8.5% of injury incidents) in 2019; 96,314 (9.2%) in 2020; and 97,841 (8.4%) in 2021. Assaults against AANHPI increased from 870 (7.1 assaults per 100 injuries) to 987 (8.3) and 1150 (7.9) between 2019 and 2021, respectively. Compared to 2019, risk of assaults in 2020 in all races increased (OR 1.08; 1.07, 1.10) but decreased in 2021 (OR 0.97; 0.96, 0.98). However, among AANHPI, risk of assaults increased in both 2020 (OR 1.22; 1.10, 1.35) and 2021 (OR 1.13; 1.03, 1.25). Most AANHPI assault victims were between 25 and 34 y old (11.8% in 2019) with an increase in 2020 (15.6%) and 2021 (14.4%). Assaults against AANHPI with blunt and sharp objects increased annually from 2019 to 2021. CONCLUSIONS: Despite national decreases of assaults in 2021 to pre-COVID baseline, the rate of assaults treated by emergency medical services for the AANHPI population remained elevated. Further studies analyzing in-hospital assault trends will allow for better understanding and will quantify the impact the pandemic and surrounding social influences had on minorities across the United States.

Identification of Clinical Risk Factors Affecting Patient-Physician Communication.

INTRODUCTION: Patient satisfaction is an important indicator of quality in health care and is linked to clinical outcomes, patient retention, and professional satisfaction. Patients admitted to the hospital from the emergency department may not understand their diagnosis, reason for admission or plan of care, which can adversely impact their hospital experience. We aim to identify risk factors that contribute to poor patient-physician communication and to assess the effects of raising awareness of these issues to hospital providers. METHODS: From November 2020 to April 2021, patients admitted to the surgical floor were surveyed within 24 h of admission. Relevant data were extracted through retrospective chart review. Residents and attendings were debriefed regarding the improving communication. Surveys answered before and after the brief intervention were compared. RESULTS: One hundred thirty one patients who were admitted to the surgical floor were surveyed. Nineteen did not know their diagnoses (14.5%), 29 could not explain their diagnoses (22.1%), and 28 did not know their treatment plans (21.4%). A total of 38 (29.0%) patients answered "no" to at least one question. Trauma patients (P = 0.034), patients with pain score >4 at time of admission (P = 0.038), age >65 y (P = 0.047), and patients with >3 comorbidities were more likely to answer "no" to at least one of the questions. Postintervention, a 10% reduction in number of patients answering "no" was observed. CONCLUSIONS: Trauma patients, patients with poor pain control, the elderly, and those with multiple comorbidities are more likely to experience poor patient-physician communication. Raising awareness of the importance of this matter resulted in an improvement in communication.

Effect of the Coronavirus Disease 2019 Pandemic on Suicide-Related Trauma Burden at a Level 1 Trauma Center.

Introduction: In March 2020, the first coronavirus disease 2019 (COVID-19) cases were reported in New York and a stay-at-home order was enacted soon after. Social isolation combined with pandemic-related stressors profoundly affected mental health. We hypothesize that there was an increase in violent suicide attempt during the COVID-19 pandemic lockdown compared to previous years. Methods: We queried our institutional trauma registry for total number of trauma activations and identified adult patients with International Classification of Diseases-10 diagnosis of intentional self-harm. We compared incidence during the lockdown to corresponding time periods from previous years. Demographic and injury characteristics were compared, as were outcomes such as mortality. Results: We observe a significant uptrend in patients requiring trauma intervention after suicide attempts from July 2019 through July 2020 (r = 0.8, P < 0.001) despite a significant downtrend in trauma volume at our institution during the same period (r = ‒0.7, P = 0.003). Although not statistically significant, patients attempting violent suicide during lockdown were more likely to have preexisting psychiatric diagnoses, to live alone, to have injury severity score >9, and to require surgical intervention. Three COVID-period patients died in the emergency room compared to zero in the comparison group. Conclusion: Our data show a rise in violent suicide attempts during the pandemic lockdown despite an overall decrease in trauma volume. The ramifications of a stay-at-home order seem to have the most profound impact on individuals with preexisting mental health disease. Early establishment of mental health outreach programs may mitigate the reverberating psychosocial consequences of a pandemic.

Bicyclists injured by automobiles: helmet use and the burden of injury.

Background: Given the widespread use of bicycles on public roadways, bicyclists injured in automobile collisions present a familiar problem to trauma centers worldwide. The aims of this study are to characterize the current injury patterns and to quantify independent risk factors for preventable injury and death, with a focus on helmet utilization and traumatic brain injuries. Methods: This is a retrospective study using the American College of Surgeons Trauma Quality Improvement Program database for the period 2010 to 2016. Data were abstracted for bicyclists ≥16 years of age injured by an automobile. The primary outcome of interest was mortality. The secondary outcomes included intracranial, facial, and cervical spine injuries, as well as polytrauma. We used multivariate logistic regression to identify risk factors associated with outcomes. Results: Of the 980 955 cases in the database, 7159 (0.73%) were bicyclists involved in a collision with an automobile. The median age was 45 years and 85% of patients were male. Polytraumatic occurrences accounted for 58% of injuries. Helmet use was reported in 25.4% of cases, a rate that did not change significantly during the study period. Helmet utilization was higher in those aged >65 years and in patients located in the West and Northeast regions of the USA. Helmet use was associated with an overall lower incidence of all reported forms of intracranial injuries. Overall mortality was 7.4%. Independent risk factors associated with mortality included age >65, lack of helmet use, head injury, and abdominal injury. Discussion: Bicyclists injured in collisions with an automobile are at high risk of severe injury and mortality. Preventive strategies should target older bicyclists, helmet utilization, and increasing helmet accessibility for all bicyclists using roadways. Level of evidence: Level IV.

Blunt Traumatic Innominate Artery Pseudoaneurysm Endografting without Heparin Due to Severe Brain Injury.

Blunt traumatic innominate artery injuries occur in polytrauma victims who have suffered high-speed motor vehicle collisions. Their associated injuries may preclude the use of heparin and affect surgical management and perioperative neurological risk. The uniqueness of this case is combining the arterial injury repair with a severe progressive neurological injury that prohibited standard perioperative antiplatelet or anticoagulent use.

Rib fixation in geriatric trauma: Mortality benefits for the most vulnerable patients.

BACKGROUND: Rib fractures in the geriatric trauma population are associated with significant morbidity and mortality. The outcomes of surgical stabilization of rib fractures (SSRF) have not been well defined in this population. METHODS: Data from the 2016 to 2017 Trauma Quality Improvement Program database were analyzed. Patients older than 65 years admitted with isolated chest wall injury and multiple rib fractures were abstracted from the database. Multivariate propensity score matching was utilized to stratify patients that underwent rib fixation versus nonoperative management. In the matched cohort, we assessed outcomes including mortality, intensive care unit (ICU) and hospital lengths of stay (LOS), tracheostomy rates, and ventilator-associated pneumonia (VAP) rates. We performed a secondary analysis of patients receiving early (<72 hours) versus late SSRF. RESULTS: Of the 44,450 patients included in the study analysis, 758 (1.7%) underwent SSRF. Patients undergoing SSRF were younger, had a higher prevalence of flail chest, higher rates of emergency room intubation, higher Injury Severity Score, and increased ICU admission rates. The 1:1 propensity score match resulted in 758 patients in each group. The in-hospital mortality rate was significantly lower in patients that underwent SSRF (4.2% vs. 7.3%, p = 0.01). However, the fixation group also had higher rates of tracheostomy during admission (11.2% vs. 4.6%, p < 0.001) and VAP (3.0% vs. 1.6%, p = 0.007). In a secondary matched analysis of 326 pairs of patients undergoing SSRF, we found that early fixation was associated with decreased rates of VAP (1.5% vs. 4.6%, p = 0.01), fewer ventilator days (4 days vs. 7 days, p = 0.003), shorter ICU LOS (6 days vs. 9 days, p = 0.001), and shorter hospital LOS (10 days vs. 15 days, p < 0.001). CONCLUSION: This study demonstrates a mortality benefit in geriatric trauma patients undergoing SSRF. Early SSRF was observed to be associated with decreased rates of VAP, decreased ICU LOS, and decreased hospital LOS. Early SSRF may be associated with improved outcomes in the geriatric trauma population with multiple rib fractures. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.

The MILLER banding procedure is an effective method for treating dialysis-associated steal syndrome.

We evaluated the efficacy of the Minimally Invasive Limited Ligation Endoluminal-Assisted Revision (MILLER) banding procedure in treating dialysis-associated steal syndrome or high-flow access problems. A retrospective analysis was conducted, evaluating banding of 183 patients of which 114 presented with hand ischemia (Steal) and 69 with clinical manifestations of pathologic high access flow such as congestive heart failure. Patients were assessed for technical success and symptomatic improvement, primary and secondary access patency, and primary band patency. Overall, 183 patients underwent a combined 229 bandings with technical success achieved in 225. Complete symptomatic relief (clinical success) was attained in 109 Steal patients and in all high-flow patients. The average follow-up time was 11 months with a 6-month primary band patency of 75 and 85% for Steal and high-flow patients, respectively. At 24 months the secondary access patency was 90% and the thrombotic event rates for upper-arm fistulas, forearm fistulas, and grafts were 0.21, 0.10, and 0.92 per access-year, respectively. Hence, the minimally invasive MILLER procedure appears to be an effective and durable option for treating dialysis access-related steal syndrome and high-flow-associated symptoms.