Application of the Geriatric Trauma Outcome Score in a Rural Setting.

OBJECTIVE: To retrospectively apply the Geriatric Trauma Outcome (GTO) score to the patient population of a rural South Central Appalachian level 1 trauma center and identify the potential utility of the GTO score in guiding goals of care discussions. METHODS: Trauma registry data was extracted for 5,627 patients aged 65+ from 2017 to 2021. GTO score was calculated for each patient. Descriptive statistics were calculated for age, Injury Severity Score (ISS), GTO score, receipt of red blood cells, discharge status, and code status. A simple logistic regression model was used to determine the relationship between GTO score and discharge status. The probability of mortality was then calculated using GTO score, and the distribution of code status among patients with ≤50, 51-75%, and >75% probability of mortality was examined. RESULTS: For every 10-point increase in GTO score, odds of mortality increased by 79% (OR = 1.79; P < .001). Patients had an estimated 50% probability of mortality with a GTO score of 156, 75% with 174, and 99% with a score of 234, respectively. Seventeen patients had a GTO score associated with >75% probability of mortality. Of those 17 patients, four retained a full code status. CONCLUSIONS: Our analysis demonstrates that the GTO score is a validated measure in a rural setting and can be an easily calculated metric to help determine a geriatric patient's probability of mortality following a trauma. The results of our study also found that GTO score can be used to inform goals of care discussions with patients.

Surgical Repair of Idiopathic Mid-Forearm Radial Artery Aneurysm Using a Reversed Greater Saphenous Vein Interposition Graft.

Idiopathic, non-traumatic, radial artery aneurysms are rare in medical literature. This report presents the case of a 56-year-old man who was incidentally found to have a 1.01 cm × 1.31 cm left radial artery aneurysm during a carpal tunnel workup. The patient had no other aneurysms, nor any known predisposing diseases that could explain his condition. We proceeded with surgical intervention to prevent future complications. We describe the use of a greater saphenous vein interposition graft for the repair of an idiopathic mid-forearm radial artery aneurysm. The patient had an uncomplicated recovery course following repair.

Impact of Non-Automobile Rollover Accidents on Patient Outcomes at an Appalachian Level I Trauma Center.

The objective of this study was to evaluate outcomes of patients involved in rollover accidents in non-automobile vehicles in a rural level I trauma center. This was a retrospective study including a total of 127 patients over 5 years who were admitted to our level I trauma center following rollover accidents in either of the following: ATV, lawnmower, or tractor. Patients were significantly older in the tractor and lawnmower rollover groups, and patients less than 65 years old were significantly more likely to sustain an injury in a rollover accident when compared to those greater than 65. Patients with extremity fractures secondary to tractor rollovers were more likely to be older, and patients who sustained spinal injuries secondary to tractor rollovers were more likely to be younger. Non-automobile rollovers have the potential to cause traumatic injuries; however, there does not appear to be 1 vehicle type that is more prone to injury.

A National Survey Assessing the Variability in the Management of Traumatic Cardiac Arrest.

BACKGROUND: Resuscitation of traumatic cardiac arrest (TCA) is variable, with approaches that overlap Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) algorithms. There is no standard algorithm for TCA, with some withholding ACLS protocols given abysmal outcomes. This study aims to assess surgeon practices and attitudes toward resuscitation practices in TCA. MATERIALS AND METHODS: A 16-question web-based survey was distributed to the membership of a national trauma association. Respondent demographics and management of TCA were analyzed. Chi-squared tests determined statistical significance. Open-ended responses were coded and analyzed inductively. RESULTS: Two hundred and three surveys were completed. 73.4% of respondents reported utilizing ACLS, while 26.6% reported they never utilized ACLS. A statistically significant difference in the performance of ACLS was found based on number of years in practice (P = .025) and the state of practice (P = .006). There was no significant difference in self-reported survival rates or legal, ethical, or interpersonal conflicts. Qualitative data highlighted themes of interpersonal conflict and futility. DISCUSSION: This study shows that one-quarter of respondents never utilize ACLS in TCA. Of those that utilize ACLS, there was variability in the technique, indication, and duration of resuscitation. Despite significant variability in technique, there appears to be similar survival rates and incidence of conflict. The association between years in practice and ACLS use suggests this may represent an emerging change in practice. The low response rate limits generalizability; however, there is significant variability in practice, highlighting a need for evidence-based guidelines.

Facial Artery Musculomucosal Flap for Nasopharyngeal and Oropharyngeal Reconstruction.

Importance: The facial artery musculomucosal (FAMM) flap is a well vascularized axial flap which has been described for mucosal reconstructions throughout the oral cavity. There are limited data regarding its efficacy in secondary repair of nasopharyngeal stenosis and velopharyngeal insufficiency due previous surgery and scar tissue formation. Objective: This study seeks to demonstrate the efficacy of FAMM flap procedure in patients with nasopharyngeal stenosis and velopharyngeal insufficiency. Design, Setting, and Participants: A retrospective case series included patients treated for nasopharyngeal stenosis or velopharyngeal insufficiency with a FAMM flap at an academic medical center from January 1, 2012 to November 1, 2017. Patients included in the study were those who underwent a FAMM flap procedure by the senior author during the specified time period. Main Outcomes and Measures: Functional outcomes included nasopharyngeal airway patency, nasal regurgitation, and speech quality. Any postoperative complications were recorded, including flap necrosis, infection, flap failure, dehiscence, trismus and need for revision surgery. Results: A total of 6 FAMM flap procedures were performed by the senior author over the study period for the indications of this case series. Three patients had nasopharyngeal stenosis and three had velopharyngeal insufficiency. All had successful, sustained nasopharyngeal airway patency or restored velopharyngeal function. The only postoperative complication noted was trismus at the cheek donor site. There were no patients who suffered flap failure or need for revision surgery of the FAMM flap. Conclusions: The FAMM flap is useful for secondary reconstruction of nasopharyngeal stenosis and velopharyngeal insufficiency due to previous surgery and scarring. This study demonstrates the efficacy and reliability of FAMM flaps for repair of complete/near complete nasopharyngeal stenosis and cases of velopharyngeal insufficiency due to scarring of the pharynx.

Longitudinal Analysis of "Window Shade" Tympanoplasty Outcomes for Anterior Marginal Tympanic Membrane Perforations.

OBJECTIVES: Although many techniques have been proposed for the repair of tympanic membrane perforations, few address the unique challenges presented by anterior marginal perforations. In these circumstances, traditional underlay and overlay techniques are often complicated by issues including blunting of the anterior tympanomeatal angle, graft lateralization, delayed healing, and reduced graft take rates. The "window shade" tympanoplasty technique described in this paper incorporates several aspects of the underlay and overlay techniques to address these issues. STUDY DESIGN AND SETTING: A retrospective chart review was conducted at an academic medical center, of all patients who underwent window shade tympanoplasty from 1994 to 2016 by a single surgeon. PATIENTS: A total of 412 patients aged 6 to 76 years old were included in the study. Patients who had undergone concomitant ossicular chain reconstruction were excluded from the hearing outcome portion of the analysis. MAIN OUTCOME MEASURES: Any patients observed to have residual postoperative perforations within the first 6 months after surgery were considered to have graft failure. Complications such as otorrhea, serous otitis media, epithelial pearls, and post-auricular infection were tabulated. Air-bone gap closure was also assessed. RESULTS: Postoperative outcomes of 412 patients were assessed including graft take rate, complication rates, and air-bone gap closure. The graft take success rate was 94.2%. Overall complication rate was 4.6%. 82.6% of patients achieved air-bone gap closure within 10 dB. CONCLUSIONS: The results of this study further reinforce the success of the window shade technique in repairing anterior marginal tympanic membrane perforations.

First data from a parent-reported registry of 81 individuals with Coffin-Siris syndrome: Natural history and management recommendations.

Coffin-Siris syndrome (CSS; MIM 135900) is a multisystem congenital anomaly syndrome caused by mutations in the genes in the Brg-1 associated factors (BAF) complex. Classically, individuals with CSS have been described with hypo- or aplasia of the fifth digit nails or phalanges (hence the term "fifth digit syndrome"). Other physical features seen include growth restriction, coarse facial features, hypertrichosis or hirsutism, sparse scalp hair, dental anomalies, and other organ-system abnormalities. Varying degrees of developmental and intellectual delay are universal. To date, approximately 200 individuals have been described in the literature. With the advent of large-scale genetic testing such as whole-exome sequencing is becoming more available, more individuals are being found to have mutations in this pathway, and the phenotypic spectrum appears to be broadening. We report here a large cohort of 81 individuals with the diagnosis of CSS from the first parent-reported CSS/BAF complex registry in an effort to describe this variation among individuals, the natural history of the syndrome, and draw some gene-phenotype correlations. We propose that changes in the BAF complex may represent a spectrum of disorders, including both ARID1B-related nonsyndromic intellectual disability (ARID1B-ID) and CSS with classic physical features. In addition, we offer surveillance and management recommendations based on the medical issues encountered in this cohort to help guide physicians and patients' families.

Congenital methemoglobinemia type II in a 5-year-old boy.

Congenital Methemoglobinemia is a rare neurologic condition which can mimic other diseases such as epilepsy syndromes and leukodystrophies. The responsible gene, CYB5R3, is not typically included on commonly order neurologic and epilepsy panels. We recommend that laboratories include this gene on these tests which often precede larger-scale genetic studies.