Change in Code Status Orders of Hospitalized Adults With COVID-19 Throughout the Pandemic: A Retrospective Cohort Study.

Aim: Our aim was to examine how code status orders for patients hospitalized with COVID-19 changed over time as the pandemic progressed and outcomes improved. Methods: This retrospective cohort study was performed at a single academic center in the United States. Adults admitted between March 1, 2020, and December 31, 2021, who tested positive for COVID-19, were included. The study period included four institutional hospitalization surges. Demographic and outcome data were collected and code status orders during admission were trended. Data were analyzed with multivariable analysis to identify predictors of code status. Results: A total of 3615 patients were included with full code (62.7%) being the most common final code status order followed by do-not-attempt-resuscitation (DNAR) (18.1%). Time of admission (per every six months) was an independent predictor of final full compared to DNAR/partial code status (p = 0.04). Limited resuscitation preference (DNAR or partial) decreased from over 20% in the first two surges to 10.8% and 15.6% of patients in the last two surges. Other independent predictors of final code status included body mass index (p < 0.05), Black versus White race (0.64, p = 0.01), time spent in the intensive care unit (4.28, p = <0.001), age (2.11, p = <0.001), and Charlson comorbidity index (1.05, p = <0.001). Conclusions: Over time, adults admitted to the hospital with COVID-19 were less likely to have a DNAR or partial code status order with persistent decrease occurring after March 2021. A trend toward decreased code status documentation as the pandemic progressed was observed.

If Your Heart Were to Stop: Characterization and Comparison of Code Status Orders in Adult Patients Admitted with COVID-19.

Aim: Our aim is to characterize code status documentation for patients hospitalized with novel coronavirus 2019 (COVID-19) during the first peak of the pandemic, when prognosis, resource availability, and provider safety were uncertain. Methods: This retrospective cohort study was performed at a single tertiary academic medical center. Adult patients admitted between March 1, 2020 and October 31, 2020 who tested positive for COVID-19 were included. Demographic and hospital outcome data were collected. Code status orders during this admission and prior admissions were trended. Data were analyzed with multivariable analysis to identify predictors of code status choice. Results: A total of 720 patients were included. The majority (70%) were full code and 12% were in do-not-attempt resuscitation (DNAR) status on admission; by discharge, 20% were DNAR. Age (p < 0.001), time in the intensive care unit (ICU) (p < 0.001), and having Medicaid (p = 0.04) compared to private insurance were predictors of DNAR. Fourteen percent had no code status order. Older age (p < 0.001), time in the ICU (p = 0.01), and admission to a teaching service (p < 0.001) were associated with having an order. Of patients with a prior admission (n = 227), 33.5% previously had no code status order and 44.5% had a different code status for their COVID-19 admission. Of those with a change, most transitioned to less aggressive resuscitation preferences. Conclusions: Most patients hospitalized with COVID-19 in our study elected to be full code. Almost half of patients with prepandemic admissions had a different code status during their COVID-19 admission, with a trend toward less aggressive resuscitation preference.

An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

INTRODUCTION: Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS: We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS: We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION: CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. LEVEL OF EVIDENCE: Epidemiologic/Diagnostic study, level III.

A loss of profilin-1 in late-stage oral squamous cell carcinoma.

BACKGROUND: The genes for PFN1 and TMSB4 are both highly expressed in oral tissue and both encode actin monomer binding proteins thought to play a role in cell motility and possibly other crucial parts of tumor progression. METHODS: Oral brush cytology of epithelium from oral squamous cell carcinoma (OSCC) was used to measure PFN1 and TMSB4 mRNA in OSCC, while immunohistochemical analysis of tissue was used to check protein levels. RESULTS: High but variable expression of mRNAs encoding these two proteins was observed suggesting they may contribute to tumor characteristics in a subset of OSCCs. Both proteins were highly expressed in normal appearing basal epithelium, in the cytoplasm, and perinuclear area, while expression was minimal in upper epithelial layers. In OSCCs, expression of these proteins varied. In tumors classified as later stage, based on size and/or lymph node involvement, PFN1 levels were lower in tumor epithelium. A control gene, KRT13, showed expression in normal differentiated basal and suprabasal oral mucosa epithelial cells and as reported was lost in OSCC cells. CONCLUSION: Loss of PFN1 in tumor cells has been associated with lymph node invasion and metastasis in other tumor types, strengthening the argument that the protein has the potential to be a tumor suppressor in late-stage OSCC.

Contemporary management and outcomes of blunt thoracic aortic injury: a multicenter retrospective study.

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) are composed of a spectrum of lesions ranging from intimal tear to rupture, yet optimal management and ultimate outcome have not been clearly established. METHODS: This is a retrospective multicenter study of BTAIs from January 2008 to December 2013. Demographics, diagnosis, treatment, and in-hospital outcomes were analyzed. RESULTS: Nine American College of Surgeons-verified Level I trauma centers contributed data from 453 patients with BTAIs. After exclusion of patients expiring before imaging (58) and transfers (13), 382 patients with imaging diagnosis were available for analysis (Grade 1, 94; Grade 2, 68; Grade 3, 192; Grade 4, 28). Hypotension was present on admission in 56 (14.7%). Computed tomographic angiography was used for diagnosis in 94.5%. Nonoperative management (NOM) was selected in 32%, with two in-hospital failures (Grade 1, Grade 4) requiring endovascular salvage (thoracic endovascular aortic repair [TEVAR]). Open repair (OR) was completed in 61 (16%). TEVAR was conducted in 198 (52%), with 41% of these requiring left subclavian artery coverage. Complications of TEVAR included endograft malposition (6, 3.0%), endoleak (5, 2.5%), paralysis (1, 0.5%), and stroke (2, 1.0%). Six TEVAR failures were treated by repeat TEVAR (2) or OR (4). Overall in-hospital mortality was 18.8%, and aortic-related mortality was 6.5% (NOM, 9.8%; OR, 13.1%; TEVAR, 2.5%) (Grade 1, 0%; Grade 2, 2.9%; Grade 3, 5.2%; Grade 4, 46.4%). The majority of aortic-related deaths (18 of 25) occurred before the opportunity for repair. Independent predictors of aortic-related mortality among BTAI patients were higher chest Abbreviated Injury Scale (AIS) score, grade, and Injury Severity Score (ISS); TEVAR was protective (p = 0.03; odds ratio, 0.21; confidence interval, 0.05-0.88). CONCLUSION: Failures and aortic-related mortality of NOM following BTAI Society of Vascular Surgery Grade 1 to 3 injuries are rare. TEVAR seems independently protective against aortic-related mortality. Early complications of TEVAR have decreased relative to previous reports. Prospective long-term follow-up data are required to better refine indications for intervention. LEVEL OF EVIDENCE: Level IV.

Pneumatosis Intestinalis Predictive Evaluation Study (PIPES): a multicenter epidemiologic study of the Eastern Association for the Surgery of Trauma.

BACKGROUND: Pneumatosis intestinalis (PI) is associated with numerous adult conditions, ranging from benign to life threatening. To date, series of PI outcomes consist of case reports and small retrospective series. METHODS: We conducted a retrospective multicenter study, involving eight centers, of PI from January 2001 to December 2010. Demographics, medical history, clinical presentation, and outcomes were collected. Primary outcome was the presence of pathologic PI defined as confirmed transmural ischemia at surgery or the withdrawal of clinical care and subsequent mortality. Forward logistic regression and a regression tree analysis was used to generate a clinical prediction rule for pathologic PI. RESULTS: During the 10-year study period, 500 patients with PI were identified. Of this number, 299 (60%) had benign disease, and 201 (40%) had pathologic PI. A wide variety of variables were statistically significant predictors of pathologic PI on univariate comparison. In the regression model, a lactate of 2.0 or greater was the strongest independent predictor of pathologic PI, with hypotension or vasopressor need, peritonitis, acute renal failure, active mechanical ventilation, and absent bowel sounds also demonstrating significance. Classification and regression tree analysis was used to create a clinical prediction rule. In this tree, the presence of a lactate value of 2.0 or greater and hypotension/vasopressor use had a predictive probability of 93.2%. CONCLUSION: Discerning the clinical significance of PI remains a challenge. We identified the independent predictors of pathologic PI in the largest population to date and developed of a basic predictive model for clinical use. Prospective validation is warranted. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Deferral of the rectal examination in blunt trauma patients: a clinical decision rule.

OBJECTIVES: To develop a clinical decision rule that would allow for the safe deferral of the digital rectal examination (DRE) in blunt trauma patients. METHODS: The authors reviewed the medical records of all adult blunt trauma patients meeting trauma team activation criteria over a 14-month period. The results of the DRE and six predictor variables-abnormal neurologic examination, abdominal tenderness, pelvic stability, blood at the urethral meatus, blood pressure < 90 mm Hg, and age over 65 years-were recorded. Patients with abnormal DREs had their discharge summaries reviewed for specific criteria to determine if the abnormal DRE was a true- or false-positive examination. Predictor variables were entered into a classification and regression tree (CART) analysis designed to predict true-positive abnormal DREs. RESULTS: Of the 579 patients, 53 had abnormal DREs, 34 of which were true positives. CART analysis retained three predictors, abnormal neurologic examination, blood at the urethral meatus, and age over 65 years, and accurately classified all patients with a true-positive abnormal DRE. The probability of a true-positive abnormal DRE in a patient with a normal neurologic examination, no blood at the urethral meatus, and age less than 65 years is between 0% and 0.8%. CONCLUSIONS: Adult patients with blunt trauma and a normal neurologic examination, with no blood at the urethral meatus, and who are less than 65 years old have an exceedingly low likelihood of a true-positive abnormal DRE. If validated, patients who meet these three criteria may have the DRE safely deferred.

Effect of tissue injury on D-Dimer levels: a prospective study in trauma patients.

BACKGROUND: D-Dimer measurement has been used as a simple, non-invasive test to rule out thromboembolic phenomena in patients at risk for deep venous thrombosis (DVT) and / or pulmonary embolism (PE). Elevated D-Dimer level caused by tissue injury is believed to show a trend for gradual decrease to normal within the first three days after trauma. MATERIAL/METHODS: To study the effect of tissue injury on D-Dimer levels, we conducted a prospective measurement of D-Dimer levels in severely traumatized, high-risk patients for DVT or PE, starting within 24 hours after admission until disposition of the patient or to a total of 14 days of hospitalization. Patients were observed clinically for development of thromboembolic phenomena, and were subjected to weekly surveillance using duplex scan of the lower extremities. Additional testing was done if requested by the attending trauma surgeon. RESULTS: A total of 21 patients were enrolled in the study. There were 17 males, and 4 females. Patients had a mean age of (42) with a range of (17-79), and a mean ISS score of (20) with a range of (4-50). Seven patients completed 3-9 days of testing. Fourteen patients had more than 10 days of testing. Nine patients completed 14 days of testing. In all patients, tissue injury resulted in increased levels of D-Dimer above a threshold (500 ng/ml), below which DVT or PE can be ruled out. The increased levels failed to normalize even when testing was continued for 14 days. CONCLUSIONS: In our study, the increased D-Dimer levels induced by tissue injury failed to show a trend of gradual return to normal within three days after trauma, as currently believed. This, in our opinion, may eliminate our ability to use D-Dimer testing to rule out DVT or PE in a subset of severely traumatized patients in the early post trauma period.