Hospital Volume of Emergency General Surgery and its Impact on Inpatient Mortality for Geriatric Patients: Analysis From 3994 Hospitals.

BACKGROUND: Previous investigations have shown a positive association between hospital volume of operations and clinical outcomes. However, it is unclear whether such relationships also apply to emergency surgery. We sought to examine the association between hospital case volume and inpatient mortality for 7 common emergency general surgery (EGS) operations among geriatric patients. METHODS: This is a population based retrospective cohort study using the Centers of Medicare and Medicaid Services (CMS) Limited Dataset Files (LDS) from 2011 to 2013. The 7 most common emergency surgeries included (1) partial colectomy, (2) small-bowel resection (SBR), (3) cholecystectomy, (4) appendectomy, (5) lysis of adhesions (LOA), (6) operative management of peptic ulcer disease (PUD), and (7) laparotomy with the primary outcome being inpatient mortality. Risk-adjusted inpatient mortality was plotted against operative volume. Subsequently an operative volume threshold was calculated using a best fit regression method. Based on these estimates, high- and low-volume hospitals were compared to examine significance of outcomes. Significance was defined as P-value < .05. RESULTS: The final cohort comprised of 414 779 patients from 3994 hospitals. The standardized mortality ratio (SMR) for high-volume centers were lower in 6 out of 8 surgeries examined. Small-bowel resection and partial colectomy operations had a significant decrease in mortality based on a volume threshold. CONCLUSION: We observed decreased mortality with higher surgical volume for small-bowel resection and partial colectomy operations. Such differences may be related to practice patterns during the perioperative period, as complications related to the perioperative care were significantly lower for high-volume centers.

Increased Mortality in Hip Fracture Patients With Aortic Stenosis and Pulmonary Hypertension Compared to Aortic Stenosis Alone.

INTRODUCTION: Hip fractures are one of the most common traumatic injuries in the United States, secondary to an aging population. Multiple comorbidities are found in patients who present to trauma centers (TCs) with isolated hip fractures (IHFs) including significant cardiac disease. Aortic stenosis (AS) among these patients has been recently shown to increase mortality. However, factors leading to death from AS are unknown. We hypothesize that pulmonary hypertension (PH) is a significant mechanism of death among IHF patients with AS. METHODS: This is a multicenter retrospective cohort study examining IHF patients treated at Level I and II TCs within a large hospital system from 2015 to 2019. Patients who had IHFs and AS were compared to those who had IHFs, AS, and PH. Multivariable logistic regression was used to risk adjust by age, race, insurance status, and comorbidities. The primary outcome was inpatient mortality. The secondary outcomes were hospital-acquired complications. RESULTS: A total of 1388 IHF patients with AS were included in the study. Eleven percent of these patients also had PH. The crude mortality rate was higher if IHF patients had both AS and PH compared to IHF with AS alone (9% vs 3.7%, P-value .003). After risk adjustment, a higher risk of mortality was still significant (aOR 2.56 [95% CI 1.28, 5.11]). In addition, IHF patients with both AS and PH had higher complication rates; the exposure group had higher percentage of pulmonary embolism (1.4% vs .2%, adjusted P-value .03), new-onset congestive heart failure (4.1% vs 1%, adjusted P-value .01), and sepsis/septicemia (3.5% vs 1.4%, adjusted P-value .05). CONCLUSION: In patients with IHFs, PH and AS increase the likelihood of inpatient mortality by 2.5 times compared to AS alone. Pulmonary hypertension among IHF patients with AS is an important risk factor to identify in the preoperative period. Early identification may lead to better perioperative management and counseling of patients at higher risk of complications.

The Statewide Epidemiology of Mucormycosis Among Trauma Patients in Florida.

OBJECTIVES: Mucormycosis is a rare angioinvasive infection caused by filamentous fungi with a high lethality among the immunocompromised. In healthy people, the innate immune system is sufficient to prevent infection. The exception to this is deep tissue exposure seen during trauma. The purpose of this study is to evaluate the epidemiology of mucormycosis using a statewide population-based data set. METHODS: This is a retrospective cohort study of all hospital admissions for mucormycosis within the state of Florida from 1997 through the beginning of 2020. A distribution map was created to evaluate for geographic variation. Botanical growth zones, based on plant hardiness, used by state environmental agencies and landscapers were also used to detect possible patterns based on climate conditions throughout Florida. A multivariable regression analysis was performed to account for confounders and limit bias. RESULTS: A total of 1190 patients were identified for mucormycosis infection. Only 86 of these patients were admitted for trauma. Cutaneous infections were more prevalent among trauma patients while non-trauma patients had more pulmonary infections (P = .04). Trauma patients with infection tended to be younger and less likely to suffer from comorbidities such as immunosuppression (36% vs 46%, P = .07) and diabetes (22.1% vs 47.1%, P ≤ .0001) as compared to their non-trauma counterparts. Mortality was similar with 17.8% for non-trauma patients and 15.1% for traumatized patients (AOR .80 [.42, 1.52]). Length of stay was longer for trauma patients (37.3 vs 23.0, P < .0001). Infections were less prominent in plant hardiness Zone 9 and Zone 10 as compared to Zone 8 (AOR .71 [.61, .82]; AOR .54 [.46, .64], respectively). CONCLUSION: Trauma patients who develop infection from mucormycosis are at high risk of death despite being a younger and healthier population. Mucormycosis infections were primarily soft tissue based among trauma patients. These infections are more prevalent in colder regions within Florida.

Frailty Score as a Predictor of Outcomes in Geriatric Patients with Isolated Hip Fractures.

BACKGROUND: Isolated hip fractures (IHFs) are a cause of morbidity and mortality in the geriatric population aged >65 years. Frailty has been identified as a determinant for patient outcomes in other surgical specialties. The purpose of this study is to determine if frailty severity is a predictor of outcomes in IHF in the geriatric population. METHODS: This is a retrospective study in a state and ACS Level 2 trauma center. Patients with IHF were reviewed between January 2018 and January 2020. Primary outcome was in-patient mortality. Secondary outcomes include perioperative outcome measures such as UTI, HCAP, DVT, readmission, length of stay, ICU length of stay, nutritional status, and discharge destination. Patients were stratified into mild (1-2), moderate (3-5), and severe (5-7) frailty using the Rockwood Frailty Score (RFS). Clinical characteristics and outcomes were analyzed. RESULTS: We identified 470 patients with IHF who were stratified by mild (N=316), moderate (N-123), and severe (N=31) frailty. Frailty worsened with increasing age (P < .0001). Those who were less frail were more likely discharged home (P < .04). Severely frail patients were more likely discharged to hospice (P < .01). Severely frail patients also were more likely to develop DVT (P < .04) and have poorer nutritional status (P < .02). There were no differences among groups for in-patient mortality. CONCLUSION: Severely frail patients are more likely to be malnourished at baseline and be discharged to hospice care. The RFS is a reliable objective tool to identify high-risk patients and guide goals of care discussion for operative intervention in isolated traumatic hip fractures.

Undertriage of Geriatric Trauma Patients in Florida.

INTRODUCTION: Elderly undertriage rates are estimated up to 55% in the United States. This study examined risk factors for undertriage among hospitalized trauma patients in a state with high volumes of geriatric trauma patients. MATERIALS AND METHODS: This is a population-based retrospective cohort study of 62,557 patients admitted to Florida hospitals between 2016 and 2018 from the Agency for Healthcare Administration database. Severely injured trauma patients were defined by American College of Surgeons definitions and an International Classification of Disease Injury Severity Score <0.85. Undertriage was defined as definitive care of these severely injured patients at any Florida hospital other than a state-designated trauma center (TC). Univariate analyses were used to identify risk factors associated with inpatient mortality and undertriage. Multiple variable regression was used to estimate risk-adjusted odds of mortality after admission to either a designated or nondesignated TC. RESULTS: Undertriaged patients were more likely to have isolated traumatic brain injuries, lower International Classification of Disease Injury Severity Scores, multiple comorbidities, and older age. Trauma patients aged 65 and older were more than twice as likely to be undertriaged (34% versus 15.7%, P < 0.0001). Undertriaged patients of all ages were also more likely to suffer from pneumonia, urinary tract infection, arrhythmias, and sepsis. After risk adjustment, severely injured trauma patients admitted to non-TC were also more likely to be at risk for mortality (adjusted odds ratio, 1.27; 95% confidence interval, 1.17-1.38). CONCLUSIONS: Age and multiple comorbidities are significant predictors of mortality among undertriage of trauma patients. As a result, trauma triage guidelines should account for high-risk geriatric trauma patients who would benefit from definitive treatment at designated TCs.

Statewide Seasonal Variations of Infections Within the Intensive Care Unit Among the Trauma Population.

BACKGROUND: Infections within intensive care unit (ICU) are a persistent problem among the critically ill. Viral pneumonias have already been established as having a season variations. We attempt to evaluate the seasonal variations of pneumonia among the traumatically injured and the critically ill. MATERIALS AND METHODS: A retrospective cohort study among traumatized patients admitted from 1997 to 2017 to an ICU within the state of Florida was performed who were diagnosed with pneumonia. A multivariate regression analysis was performed to adjust for confounders. Time periods were divided into seasons: summer, winter, spring, and fall. A subset analysis of geriatric patients (>65 years) was also performed. RESULTS: A total of 869 553 patients were identified. The most common viral infection was influenza with adenovirus the least. The most common bacterial pneumonia was Staphylococcus aureus with Bordetella pertussis the least. Pneumonias had a seasonal variation. Compared to summer, winter had a higher likelihood of pneumonia overall (Adjusted Odds Ratio (AOR)1.13). This was seen in the spring (AOR 1.04) but not in fall (AOR 1.00). Viral infections were more pronounced (AOR 3.79) in all other seasons, while bacterial showed increased likelihood during winter (AOR 1.05). In geriatrics, pneumonia was again more likely in the winter (AOR 1.22) with both viral and bacterial infections being more pronounced during winter (AOR 4.79, AOR 1.09). DISCUSSION: Pneumonias are seen more frequently within the ICU during the winter for the traumatized patient. This held true with the critically ill geriatric population as well. This effect was observed in both viral and bacterial pneumonias.

An Early Case of Fat Embolism Syndrome Occurring Following Polytrauma.

Fat embolism syndrome (FES) is a clinical entity occurring due to the presence of fat particles in the microcirculation, typically manifesting 12-72 hours after long bone trauma with respiratory distress, altered mental status, and petechial rash. Our case is that of a 17-year-old girl who suffered multiple orthopedic injuries without intracranial trauma after being a pedestrian struck by a vehicle. Despite presenting with a normal Glasgow Coma Score (GCS), within 4 hours of presentation, she was noted to have an acute mental status change to a GCS 7 with a normal computed tomography brain. Magnetic resonance imaging of the brain was suggestive of FES which, in this patient, had a rapidly progressing course with the development of severe cerebral edema and intracranial hypertension refractory to maximal medical therapy. Our patient required bilateral craniectomies for intracranial decompression and progressed over a 2-month hospital course to have subsequent cranioplasty and functional neurologic improvement. FES requires a high index of clinical suspicion in the presence of long bone fracture with unexplained altered mental status. The clinical course can be rapidly progressing with the development of intracranial hypertension which may benefit from surgical decompression with optimistic prognosis.

Optimizing energy expenditure and oxygenation toward ventilator tolerance is associated with lower ventilator and intensive care unit days.

BACKGROUND: We hypothesize that if both energy expenditure and oxygenation are optimized (EEOO) toward ventilator tolerance, this would provide patients with the best condition to be liberated from the ventilator. We defined ventilator tolerance as having a respiratory quotient value between 0.7 and 1.0 while maintaining saturations above 98% with FIO2 70% or less and a normal respiratory rate without causing disturbances to the patient's pH. METHODS: This is a single-institution prospective cohort study of ventilator dependent patients within a closed trauma intensive care unit (ICU). The study period was over 52 months. A total of 1,090 patients were part of the primary analysis. The test group (EEOO) was compared to a historical cohort, comparing 26 months in each study group. The primary outcome of this study was number of ventilator days. Secondary outcomes included in-hospital mortality, ICU length of stay (LOS), overall hospital length of stay, tracheostomy rates, reintubation rates, and in-hospital complication rates, such as pneumonia and Acute Respiratory Distress Syndrome (ARDS) ARDS. Both descriptive and multivariable regression analyses were performed to compare the effects of the EEOO protocol with our standard protocols alone. RESULTS: The primary outcome of number of ventilator days was significantly shorter the EEOO cohort by nearly 3 days. This was significant even after adjustment for age, sex, race, comorbidities, nutrition type, and injury severity, (4.3 days vs. 7.2 days, p = 0.0001). The EEOO cohort also had significantly lower ICU days, hospital days, and overall complications rates. CONCLUSION: Optimizing the patient's nutritional regimen to ventilator tolerance and optimizing oxygenation by means of targeted pulmonary mechanics and inspired FIO2 may be associated with lower ventilator and ICU days, as well as overall complication rates. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Merkel Cell Carcinoma of the Hand: A Case Report and Review of the Literature.

Background: Merkel cell carcinoma (MCC) is a relatively rare and aggressive cutaneous neuroendocrine malignancy characterized by high incidence of local recurrence, distant metastases, regional nodal metastases, and high mortality. Clinically, MCC presents as a persistent asymptomatic red/pink shaped nodule, usually smaller than 2 cm with nontender intracutaneous swelling, with rapidly growing localized disease with lymph node metastases preceding distant metastases. Because of its rare nature and the lack of comprehensive understanding of the disease, management of MCC has been controversial. Methods: An 87-year-old retired Caucasian male with a history of tobacco use, chronic sun exposure, and multiple squamous and basal cell carcinomas presented with a 1.8 × 1.3 cm red, nontender nodule on the dorsum of the proximal phalanx of the left long finger first noticed 6 months prior to presentation. Biopsy was consistent with MCC after which he was treated with wide local excision, full-thickness skin grafting, and sentinel lymphadenectomy (1/4 nodes positive) followed by adjuvant radiation therapy. Results: He recovered appropriately and was clinically and radiographically disease free at 2.5-year follow-up. Conclusion: Although it remains rare, MCC has increased in incidence over the last several decades and has a predilection to occur over sun exposed areas. Highly aggressive, it has a high incidence of regional and distant metastasis as well as local recurrence. As a result, it is important that practitioners involved in the care of skin and hand lesions be aware of this condition and the need for a multidisciplinary treatment approach.

A protocol for the management of adhesive small bowel obstruction.

BACKGROUND: Differentiating between partial adhesive small bowel obstruction (aSBO) likely to resolve with medical management and complete obstruction requiring operative intervention remains elusive. We implemented a standardized protocol for the management of aSBO and reviewed our experience retrospectively. METHODS: Patients with symptoms of aSBO were admitted for intravenous fluid resuscitation, bowel rest, nasogastric tube decompression, and abdominal examinations every 4 hours. Laboratory values and a computed tomography scan of the abdomen and pelvis with intravenous contrast were obtained. Patients with peritonitis or computed tomography scan findings suggesting bowel compromise were taken to the operating room for exploration following resuscitation. All other patients received 80 mL of Gastroview (GV) and 40 mL of sterile water via nasogastric tube. Abdominal plain films were obtained at 4, 8, 12, and 24 hours. If contrast did not reach the colon within 24 hours, then operative intervention was performed. RESULTS: Over 1 year, 91 patients were admitted with aSBO. Sixty-three patients received GV, of whom 51% underwent surgery. Twenty-four patients went directly to the operating room because of clinical or imaging findings suggesting bowel ischemia. Average time to surgery was within 1 day for the no-GV group and 2 days for the GV group. Patients passing GV to the colon within 5 hours of administration had a 90% rate of resolution of obstruction. There was a direct relationship between the duration of time before passing GV to the colon and hospital length of stay (HLOS) (r = 0.459). Patients who received GV and did not require surgery had lower HLOS (3 days vs. 11 days, p < 0.0001). CONCLUSION: The GV protocol facilitated early recognition of complete obstruction. Administration of GV had diagnostic and therapeutic value and did not increase HLOS, morbidity, or mortality. LEVEL OF EVIDENCE: Therapeutic study, level V. Epidemiologic study, level V.

Acute surgical management of hand burns.

A hand represents 3% of the total body surface area. The hands are involved in close to 80% of all burns. The potential morbidity associated with hand burns can be substantial. Imagine a patient carrying a pan of flaming cooking oil to the doorway or someone lighting a room-sized pile of leaves and branches doused with gasoline. It is clear how the hands are at risk in these common scenarios. Not all burn injuries will require surgical intervention. Recognizing the need for surgery is paramount to achieving good functional outcomes for the burned hand. The gray area between second- and third-degree burns tests the skill and experience of every burn/hand surgeon. Skin anatomy and the size of injury dictate the surgical technique used to close the burn wound. In addition to meticulous surgical technique, preoperative and postoperative hand therapy for the burned hand is essential for a good functional outcome. Recognizing the burn depth is paramount to developing the appropriate treatment plan for any burn injury. This skill requires experience and practice. In this article, we present an approach to second- and third-degree hand burns.

Hospital-acquired infections and thermally injured patients: chlorhexidine gluconate baths work.

BACKGROUND: Thermally injured patients are at high risk for infections, including hospital acquired infections (HAIs). We modeled a twice-daily chlorhexidine gluconate (CHG) bath protocol aimed at decreasing HAIs. METHODS: Bathing with a 0.9% CHG solution in sterile water was provided twice daily as part of routine care. Institutional HAI prevention bundles were in place and did not change during the study. Baseline HAI rates were collected for 12 months before the quality study implementation. Centers for Disease Control and Prevention definitions for HAIs were used; our blinded Infection Control physician made each determination. This was an Institutional Review Board-exempt protocol. RESULTS: The study cohort included 203 patients before the quality trial and 277 patients after the quality trial. The median burn area was 25% of total body surface area. Baseline HAI rates were as follows: ventilator-associated pneumonia, 2.2 cases/1,000 ventilator-days; cathether-associated urinary tract infection, 2.7 cases/1,000 catheter-days; central line-associated bloodstream infection, 1.4 cases/1,000 device-days. With implementation of this protocol, the rates dropped to zero and have stayed at that level with the exception of 1 cathether-associated urinary tract infection. There were no untoward effects or observed delays in wound healing with this protocol. All of these changes were clinically significant, although not statistically significant; the study was not powered for statistical significance. CONCLUSIONS: Using this nurse-driven protocol, we decreased, in a sustainable manner, the HAI rate in our intensive care unit to zero. No integumentary difficulties or wound healing delays were related to this protocol.

Vascularized plantar myocutaneous free flap transfer for amputee stump preparation: a proof of concept cadaver study.

Lower extremity amputee stump ulceration, irritation, and pain have been a deterrent to consistent long-term or continuous use of lower extremity prosthetics. This study is the first in a series that hypothesizes that these complications can be minimized through the insetting of a vascularized plantar free flap (VPFF) on the amputee stump. Using three hip disarticulated cadaver specimens, a VPFF was designed, dissected, and implanted on one transfemoral and two transtibial stumps. Using accepted vascular anastomosis techniques, the posterior tibial artery was anastomosed to the distal femoral or popliteal artery with corresponding anastomoses for venous drainage. In addition, the possibility of a limited to partial sensate flap may be created with a neurorrhaphy of the associated nerves. This potentially sensate area would provide plantar skin that aids the existing local sensate flap used to close the defect. It is hypothesized that this procedure offers significant rehabilitative and long-term benefits to battlefield or other acute causes for lower extremity amputation. The procedure can be accomplished in battlefield surgical setting as an immediate or delayed inset for some but not all traumatic amputations. Salvaging a partial or complete VPFF from a traumatized foot will obviously be predicated on the degree of trauma to the donor tissue.

Predicting resource utilization of elderly burn patients in the baby boomer era.

BACKGROUND: Census predictions for Florida suggest a 3-fold increase in the 65 and older population within 20 years. We predict resource utilization for burn patients in this age group. METHODS: Using the Florida Agency for Healthcare Administration admission dataset, we evaluated the effect of age on length of stay, hospital charges, and discharge disposition while adjusting for clinical and demographic factors. Using US Census Bureau data and burn incidence rates from this dataset, we estimated future resource use. RESULTS: Elderly patients were discharged to home less often and were discharged to short-term general hospitals, intermediate-care facilities, and skilled nursing facilities more often than the other age groups (P < .05). They also required home health care and intravenous medications significantly more often (P < .05). Their length of stay was longer, and total hospital charges were greater (P < .05) after adjusting for sex, race, Charleson comorbidity index, payer, total body surface area burned, and burn center treatment. CONCLUSIONS: Our data show an age-dependent increase in the use of posthospitalization resources, the length of stay, and the total charges for elderly burn patients.

Bacillus cereus necrotizing fasciitis in a patient with end-stage liver disease.

BACKGROUND: Bacillus cereus has been increasingly recognized as a virulent pathogen, particularly in immunocompromised patients. METHODS: Presented is a case report of a 24-year-old man with end-stage liver disease secondary to primary sclerosing cholangitis, who developed necrotizing fasciitis of the right lower leg due to B. cereus. The bacterium isolated from the patient was compared with environmental strains for quantity of secreted proteins as well as hemolytic and cytotoxic activities. RESULT: Despite above-the-knee amputation and aggressive antibiotic therapy, the patient expired on hospital day 13. The patient isolate demonstrated a protein secretion pattern and cytotoxicity similar to those of an environmental strain known to produce exotoxins. However, the isolate did produce a larger ratio of zone of hemolysis to colony size on blood agar plates compared with the environmental strain. CONCLUSION: To the best of our knowledge, this is the only report of B. cereus as the etiology of necrotizing fasciitis in a patient with end-stage liver disease. Because the infecting bacterium correlates with the environmental strain, the severity of the patient's disease is likely related to his immunocompromised state. Therefore, B. cereus should be considered a potential pathogen rather than a contaminant.

All-terrain vehicle safety in Florida: is legislation really the answer?

Florida is among the nation's leaders in all-terrain vehicle (ATV)-related injuries and fatalities. We hypothesized that patients sustaining injuries while in compliance with ATV laws would demonstrate less severe injury patterns and improved outcomes when compared with noncompliant patients. We reviewed patients treated for ATV-related injuries over a 36-month period. We grouped patients according to conformity with Florida statutes and compared demographics, admission status, injuries sustained, and outcome measures. Three hundred seventy-seven patients were treated for ATV-related injuries. In 294 cases, sufficient data existed to assess compliance with Florida's statutes regarding ATV rider safety: safety helmet use for persons younger than age 16 years and prohibition of ATV operation on roadways. Forty-three per cent (n = 126) had violated one or both statutes; 57 per cent (n = 168) had violated neither. The group in violation was younger (15 vs 24 years, P < 0.001) and wore helmets less often (6 vs 34%, P < 0.001). Groups required admission at similar rates (62% violators vs 60% nonviolators, P = 0.770), showed similar injury patterns, and had comparable mortality rates (2% violators vs 5% nonviolators, P = 0.451). Current Florida laws are inadequate to prevent ATV-related injuries and their sequelae. This issue should be addressed through an increased focus on safety education for ATV operators.