A prospective comparative study of the functional results associated with the use of Björk flap tracheostomy versus standard tracheostomy.

BACKGROUND: Placement of a tracheostomy for patients requiring prolonged mechanical ventilation (PMV) improves patients' comfort, decreases dead space ventilation, allows superior airway hygiene, and reduces the incidence of ventilator-associated pneumonia. Controversy still exists regarding the role of standard tracheostomy (ST) as opposed to the less frequently done Björk flap tracheostomy (BFT). This study compares the functional outcomes of these two techniques. STUDY DESIGN: Seventy-nine patients receiving tracheostomy in a 12-month period: 38 BFT vs. 41 ST. Data included demographics, indications for PMV, ventilator days before tracheostomy, time to and a number of patients who passed the fiberoptic endoscopic evaluation of swallowing (FEES), time to and a number of patients decannulated. RESULTS: Indications in both groups were PMV from trauma (18/38 vs 15/41), pneumonia (13/38 vs 13/41), and ARDS (7/38 vs 11/4), respectively (p > 0.05). Patients in both groups did not differ with regard to age, sex, GCS, duration of PMV before tracheostomy, the time to and a number of patients who passed the 1st FEES. However, the number of days and the number of FEES required before the next successful FEES in the 20 BFT and 21 ST patients who failed the 1st was 9 (4) vs. 16 (5), and 2 (1) vs. 4 (1), respectively (p < 0.05). Additionally, the number of intraoperative complications in aggregate were 0/38 in the BFT as opposed to 6/41 in the ST group (p < 0.05). CONCLUSION: We conclude that BFT may be associated with an overall shorter time to restoration of normal swallowing when compared to ST.

Early versus delayed complex abdominal wall reconstruction with biologic mesh following damage-control surgery.

BACKGROUND: Damage-control surgery for trauma and intra-abdominal catastrophe is associated with a high rate of morbidities and postoperative complications. This study aimed to compare the outcomes of patients undergoing early complex abdominal wall reconstruction (e-CAWR) in acute settings versus those undergoing delayed complex abdominal wall reconstruction (d-CAWR). METHOD: This study was a pooled analysis derived from the retrospective and prospective database between the years 2013 and 2019. The outcomes were compared for differences in demographics, presentation, intraoperative variables, Ventral Hernia Working Grade (VHWG), US Centers for Disease Control and Prevention wound class, American Society of Anesthesiologists (ASA) scores, postoperative complications, hospital length of stay, and readmission rates. We performed Student's t test, χ2 test, and Fisher's exact test to compare variables of interest. Multivariable linear regression model was built to evaluate the association of hospital length of stay and all other variables including the timing of complex abdominal wall reconstruction (CAWR). A p value of <0.05 was considered significant. RESULTS: Of the 236 patients who underwent CAWR with biological mesh, 79 (33.5%) had e-CAWR. There were 45 males (57%) and 34 females (43%) in the e-CAWR group. The ASA scores of IV and V, and VHWG grades III and IV were significantly more frequent in the e-CAWR group compared with the d-CAWR one. Postoperatively, the incidence of surgical site occurrence, Clavien-Dindo complications, comprehensive complication index, unplanned reoperations, and mortality were similar between the two groups. Backward linear regression model showed that the timing of CAWR (ß = -11.29, p < 0.0001), ASA (ß = 3.98, p = 0.006), VHWG classification (ß = 3.62, p = 0.015), drug abuse (ß = 13.47, p = 0.009), and two comorbidities of cirrhosis (ß = 12.34, p = 0.001) and malignancy (ß = 7.91, p = 0.008) were the significant predictors of the hospital length of stay left in the model. CONCLUSION: Early CAWR led to shorter hospital length of stay compared with d-CAWR in multivariable regression model. LEVEL OF EVIDENCE: Therapeutic, level IV.

Firearm Deaths are Increasing and Endemic in the USA: It is a Problem of Suicides and Not Homicides.

BACKGROUND: To analyze and report on the changes in epidemiology traumatic causes of death in the USA. METHODS: Data were extracted from the annual National Vital Statistics Reports (2008-2017) from Center for Disease Control and analyzed for trends during the time period given. Generalized additive model was applied to evaluate the significance of trend using R software. RESULTS: Firearm deaths (39,790) and firearm death rate (12.2/100,000) in 2017 were the highest reported, and this increasing trend was significant (p < 0.001) the last ten years. Deaths from motor vehicle crash (MVC) and firearm homicides did not change significantly during the same time period. Firearm deaths were lower than MVC deaths by 21% (8,197/39,790) in 2008, but after 10 years, the difference was only 1% (458/40,231). Years of life lost from firearms is now higher than MVC. Suicides by firearm in 2017 were the highest reported at 23,854/39,773 (60%). In 2017, suicides by firearm victims were predominantly white 20,328/23,562 (85%), men 20,362/23,562 (86%), and the largest group was between the ages of 55-64. CONCLUSIONS: Death from firearms in the USA is increasing and endemic. They were the highest ever reported in 2017 by the CDC. While deaths from MVC used to be the main cause of traumatic death in the USA, deaths from firearms now almost equal it. Calculated years of life lost from firearms is now more than from MVC. Most firearm deaths are not from homicides but are from suicides, and they are predominantly in white older males of the baby boomer generation (born 1946-1964).

Body Mass Index and Mortality in Blunt Trauma: The Right BMI can be Protective.

BACKGROUND: There are limited studies examining the role of BMI on mortality in the trauma population. The aim of this study was to analyze whether the "obesity paradox" exists in non-elderly patients with blunt trauma. METHODS: A retrospective study was performed on the Trauma Quality Improvement Program (TQIP) database for 2016. All non-elderly patients aged 18-64, with blunt traumatic injuries were identified. A generalized additive model (GAM) was built to assess the association of mortality and BMI adjusted for age, gender, race, and injury severity score (ISS). RESULTS: 28,475 patients (mean age = 42.5, SD = 14.3) were identified. 20,328 (71.4%) were male. Age (p < 0.0001), gender (p < 0.0001), and ISS (p < 0.0001) had significant associations with mortality. After GAM, BMI showed a significant U-shaped association with mortality (EDF = 3.2, p = 0.003). A BMI range of 31.5 ± 0.9 kg/m2 was associated with the lowest mortality. CONCLUSION: High BMI can be a protective factor in mortality within non-elderly patients with blunt trauma. However, underweight or morbid obesity suggest a higher risk of mortality.

Predicting the need for tracheostomy in trauma patients without severe head injury.

BACKGROUND: Early tracheostomy is recommended in patients with severe traumatic brain injury (TBI); however, predicting the timing of tracheostomy in trauma patients without severe TBI can be challenging. METHODS: A one year retrospective analysis of all trauma patients who were admitted to intensive Care Unit for > 7 days was performed, using the ACS-TQIP database. Univariate and Multivariate regression analyses were performed to assess the appropriate weight of each factor in determining the eventual need for early tracheostomy. RESULTS: A total of 21,663 trauma patients who met inclusion and exclusion criteria were identified. Overall, tracheostomy was performed in 18.3% of patients. On multivariate regression analysis age >70, flail chest, major operative intervention, ventilator days >5 days and underlying COPD were independently associated with need of tracheostomy. Based on these data, we developed a scoring system to predict risk for requiring tracheostomy. CONCLUSION: Age >70, presence of flail chest, need for major operative intervention, ventilator days >5 and underlying COPD are independent predictors of need for tracheostomy in trauma patients without severe TBI.

Developing a Simple Clinical Score for Predicting Mortality and Need for ICU in Trauma Patients.

Several models exist to predict trauma center need in the prehospital setting; however, there is lack of simple clinical tools to predict the need for ICU admission and mortality in trauma patients. The aim of our study was to develop a simple clinical tool that can be used with ease in the prehospital or emergency setting and can reliably predict the need for ICU admission and mortality in trauma patients. We abstracted one year of National Trauma Data Bank for all patients aged ≥ 18 years. Transferred patients and those dead on arrival were excluded. Patient demographics, injury parameters, vital signs, and Glasgow Coma Scale (GCS) were recorded. Our primary outcome measures were mortality and ICU admission. Logistic regression analysis was performed using three variables (age > 55 years, shock index (SI) > 1, and GCS score) to determine the appropriate weights for predicting mortality. Appropriate weights derived from regression analysis were used to construct a simple SI, age, and GCS (SAG) score, and associated mortality and ICU admissions were calculated for three different risk groups (low, intermediate, and high). A total of 281,522 patients were included. The mean age was 47 ± 20 years, and 65 per cent were male. The overall mortality rate was 2.9 per cent, and the rate of ICU admission was 28.7 per cent. The SAG score was constructed using weights derived from regression analysis for age ≤ 55 years (4 points), SI < 1 (3 points), and GCS (3-15 points). The median [IQR] SAG score was 21 [18-22]. The area under the receiver operating curve [95% Confidence Interval (CI)] of the SAG score for predicting mortality and ICU admission was 0.873 [0.870-0.877] and 0.644 [0.642-0.647], respectively. Each 1-point increase in the SAG score was associated with 18 per cent lower odds of mortality (odds ratio [95% CI]: 0.822 [0.820-0.825]) and 10 per cent lower odds of ICU admission (odds ratio [95% CI]: 0.901 [0.899-0.902]). The SAG score is a simple clinical tool derived from variables that can be assessed with ease during the initial evaluation of trauma patients. It provides a rapid assessment and can reliably predict mortality and need for ICU admission in trauma patients. This simple tool may allow early resource mobilization possibly even before the arrival of the patient.

Gene expression profiling identifies potential molecular markers of papillary thyroid carcinoma.

BACKGROUND: Thyroid cancer is the most common endocrine malignancy worldwide, with the predominant form papillary thyroid carcinoma (PTC) representing approximately 80% of cases. OBJECTIVE: This study was addressed to identify potential genes and pathways involved in the pathogenesis of PTC and potential novel biomarkers for this disease. METHODS: Gene expression profiling was carried out by DNA microarray technology. Validation of microarray data by qRT-PCR, western blot, and enzyme linked immunosorbent assay was also performed in a selected set of genes and gene products, with the potential to be used as diagnostic or prognostic biomarkers, such as those associated with cell adhesion, extracellular matrix (ECM) remodeling and immune/inflammatory response. RESULTS: In this study we found that upregulation of extracellular activities, such as proteoglycans, ECM-receptor interaction, and cell adhesion molecules, were the most prominent feature of PTC. Significantly over-expressed genes included SDC1 (syndecan 1), SDC4 (syndecan 4), KLK7 (kallikrein-related peptidase 7), KLK10 (kallikrein-related peptidase 10), SLPI (secretory leukocyte peptidase inhibitor), GDF15 (growth/differentiation factor-15), ALOX5 (arachidonate 5-lipoxygenase), SFRP2 (secreted Frizzled-related protein 2), among others. Further, elevated KLK10 levels were detected in patients with PTC. Many of these genes belong to KEGG pathway "Proteoglycans in cancer". CONCLUSIONS: Using DNA microarray analysis allowed the identification of genes and pathways with known important roles in malignant transformation, and also the discovery of novel genes that may be potential biomarkers for PTC.

Mortality rates of severe traumatic brain injury patients: impact of direct versus nondirect transfers.

BACKGROUND: Direct transport of patients with severe traumatic brain injury (sTBI) to trauma centers (TCs) that can provide definitive care results in lower mortality rates. This study investigated the impact of direct versus nondirect transfers on the mortality rates of patients with sTBI. METHODS: Data on patients with TBI admitted between January 1, 2012, and December 31, 2013, to our Level I TC were obtained from the trauma registry. Data included patient age, sex, mechanism, and type of injury, comorbidities, Glasgow Coma Scale, Injury Severity scores, prehospital time, time to request and to transfer, time to initiation of multimodality monitoring and goal-directed therapy protocol, dwell time in the emergency department (EDT), and mortality. Data, reported in means ± standard deviation, were analyzed with the Student t-test and chi-square. Statistical significance was accepted at a P value < 0.05. RESULTS: sTBI direct transfer to TC versus transfer from non-TCs (NTC): Of the 1187 patients with TBI admitted to our TC, 768 (64.7%) were admitted directly from the scene, whereas 419 (35.3%) were admitted after secondary transfer. One hundred seventy-one (22.2%) of the direct transfers had Glasgow Coma Scale < 8 (sTBI) and 92 (21.9%) of the secondary transfers had sTBI. The transfer time: Time from scene to arrival to the EDT was significantly shorter for TC versus NTCs 43 ± 14 versus 77 ± 26 min, respectively (P < 0.05). EDT dwell time before transfer and time from injury to arrival to TC were 4.2 ± 2.1 and 6.2 ± 8.3 h, respectively. Mortality: There was a statistically significant lower mortality for patients with sTBI transferred directly from the scene to TCs as opposed to patients secondarily transferred, 33/171 (19.3%) versus 33/92 (35.8%), respectively (P < 0.05). CONCLUSIONS: To decrease TBI-related mortality, patients with suspected sTBI should be taken directly to a Level I or II TC unless they require life-saving stabilization at NTCs.

3,3'-Diindolylmethane, a cruciferous vegetable derived synthetic anti-proliferative compound in thyroid disease.

Considerable epidemiological evidence exists to link thyroid disease with differing patterns of dietary consumption, in particular, cruciferous vegetables. We have been studying the anti-thyroid cancer (TCa) activity of indole-3-carbinol (I3C) found in cruciferous vegetables and its acid catalyzed dimer, 3,3'-diindolylmethane (DIM). There are no studies as yet to elucidate the effect of these compounds on the altered proliferative patterns in goiter or thyroid neoplasia. In this study, we tested the anti-proliferative effects of I3C and DIM on four different thyroid cancer cell lines representative of papillary (B-CPAP and 8505-C) and follicular carcinoma of the thyroid (CGTH-W-1 and ML-1), and primary human goiter cells. Cell survival and IC50 values for I3C and DIM were calculated by the XTT assay and cell cycle distribution analysis was done by flow cytometry. DIM was found to be a better anti-proliferative agent than I3C in both papillary and follicular TCa resulting in a greater cytotoxic effect at a concentration over three fold lower than predicted by the molar ratio of DIM and I3C. The anti-proliferative activity of DIM in follicular TCa was mediated by a G1 arrest followed by induction of apoptosis. DIM also inhibited the growth of primary goiter cells by 70% compared to untreated controls. Contrary to traditional belief that cruciferous vegetables are "goitrogenic", DIM has anti-proliferative effects in glandular thyroid proliferative disease. Our preclinical studies provide a strong rationale for the clinical exploration of DIM as an adjuvant to surgery in thyroid proliferative disease.