Weight-Based Dosing for Low-Molecular-Weight Heparin (Enoxaparin) Administration to Achieve Optimal VTE Prophylaxis in Trauma Patients.

INTRODUCTION: Patients admitted after traumatic injuries are at high risk for developing venous thromboembolism (VTE). Low-molecular-weight heparin (LMWH) is commonly used to prevent VTE in this patient population; however, the optimal dosing strategy has yet to be determined. To address this question, a fixed-dosing strategy of LMWH was compared to a weight-based dosing strategy of LMWH for VTE prophylaxis. METHODS: A retrospective, pre-post implementation cohort study compared a fixed vs a weight-based dosing strategy of LMWH for VTE prophylaxis. Patients admitted to our level 1 trauma center were included if they had an estimated glomerular filtration rate >30 mL/min/1.73 m2, received at least 3 doses of LMWH, and had an appropriately drawn anti-Xa level on their initial dosing regimen. Patients in the pre-cohort received 30 mg LMWH subcutaneously twice daily as the initial dosing regimen. Patients in the post-cohort received .5 mg/kg (max 60 mg) LMWH subcutaneously every 12 h as the initial dosing regimen. A goal anti-Xa of .2-.4 IU/mL was targeted for prophylaxis. RESULTS: There were 817 patients in the fixed-dosing group (FDG) and 874 patients in the weight-based dosing group (WBDG). In the FDG, 42.8% of the patients achieved the goal initial anti-Xa level, with 54.1% and 3.1% reaching sub- and supratherapeutic doses, respectively. In the WBDG, 66.5% of patients reached goal initial anti-Xa levels, with 23.5% and 10.1% at sub- and supratherapeutic levels. The distribution of dose ranges was significantly different between the dosing strategies (P-value <.001). There was no difference in the number of patients who received blood products (39.1% vs 41.7%. P-value = .299). CONCLUSIONS: In our study, weight-based dosing of LMWH yielded a significantly higher proportion of patients who achieved goal prophylactic anti-Xa levels than fixed-dosing of LMWH. Larger-scale studies are needed to assess the risk of VTE events and bleeding with these dosing strategies.

Progressive Reduction in Preventable Mortality in a State Trauma System Using Continuous Preventable Mortality Review to Drive Provider Education: Results of Analyzing 1,979 Trauma Deaths from 2015 to 2022.

BACKGROUND: The state legislature codified and funded the Arkansas Trauma System (ATS) in 2009. Quarterly preventable mortality reviews (PMRs) by the ATS began in 2015 and were used to guide state-wide targeted education to reduce preventable or potentially preventable (P/PP) deaths. We present the results of this PMR-education initiative from 2015 to 2022. STUDY DESIGN: The ATS uses a statistical sampling model of the Arkansas Trauma Registry to select ~40% of the deaths for quarterly review, reflecting the overall the Arkansas Trauma Registry mortality population. A multispecialty PMR committee reviews the medical records from prehospital care to death, and hospital and regional advisory council reviews for each death. The PMR committee assigns opportunities for improvement (OFIs), cause(s) of death, and the likelihood of preventability for each case. Education to improve trauma care includes annual state-wide trauma meetings, novel classes targeted at level III/IV trauma center hospital providers, trauma evidence-based guidelines, and PMR "pearls." RESULTS: We reviewed 1,979 deaths with 211 (10.6%) deaths judged to be P/PP deaths. There was a progressive decrease in P/PP deaths and OFIs for P/PP deaths. Five OFI types targeted by education accounted for 72% of the 24 possible OFI types in the P/PP cases, and 94% of the "contributory OFIs." Reductions in "delay in treatment" resulted in the most rapid decrease in P/PP deaths. CONCLUSIONS: Using ongoing PMR studies to target provider education led to a reduction in P/PP deaths and OFIs for P/PP deaths. Focusing on education designed to improve preventable mortality can result in a substantial decrease in P/PP deaths by 43% (14% to 8%) for trauma systems.

The silent killer: Previously undetected pulmonary emboli that result in death after discharge.

INTRODUCTION: Pulmonary embolism (PE) is a recognized cause of death in hospitalized trauma patients, yet less is known about PE after discharge. PATIENTS & METHODS: All post-discharge, autopsy-demonstrated, fatal PE resulting from trauma within a large US county over six years were analyzed. Counts, percentages, mean values, SD, and IQR were calculated for all variables. RESULTS: 1848 trauma deaths were reviewed, of which 85% had an autopsy. Eighty-five patients died from PE after discharge from their initial injury. 53% were initially treated at non-trauma centers, and 9% did not seek medical assistance. 75% were injured by falling, and most injuries occurred in the lower extremities. 86% had an ISS <16, but 87% needed assistance or were bed-bound after injury, despite 75% having no mobility limitations before the injury. 53% died within one month of injury, and 91% within the first year. Before death, only 11% were prescribed chemical thromboprophylaxis or an antiplatelet agent, and only 8% were diagnosed with venous thromboembolism before death. CONCLUSIONS: Fatal PE after discharge typically occurred following activity-limiting lower extremity injuries with an ISS<16.

Subscriptions and external links help drive resentful users to alternative and extremist YouTube channels.

Do online platforms facilitate the consumption of potentially harmful content? Using paired behavioral and survey data provided by participants recruited from a representative sample in 2020 (n = 1181), we show that exposure to alternative and extremist channel videos on YouTube is heavily concentrated among a small group of people with high prior levels of gender and racial resentment. These viewers often subscribe to these channels (prompting recommendations to their videos) and follow external links to them. In contrast, nonsubscribers rarely see or follow recommendations to videos from these channels. Our findings suggest that YouTube's algorithms were not sending people down "rabbit holes" during our observation window in 2020, possibly due to changes that the company made to its recommender system in 2019. However, the platform continues to play a key role in facilitating exposure to content from alternative and extremist channels among dedicated audiences.

Challenges in Understanding Human-Algorithm Entanglement During Online Information Consumption.

Most content consumed online is curated by proprietary algorithms deployed by social media platforms and search engines. In this article, we explore the interplay between these algorithms and human agency. Specifically, we consider the extent of entanglement or coupling between humans and algorithms along a continuum from implicit to explicit demand. We emphasize that the interactions people have with algorithms not only shape users' experiences in that moment but because of the mutually shaping nature of such systems can also have longer-term effects through modifications of the underlying social-network structure. Understanding these mutually shaping systems is challenging given that researchers presently lack access to relevant platform data. We argue that increased transparency, more data sharing, and greater protections for external researchers examining the algorithms are required to help researchers better understand the entanglement between humans and algorithms. This better understanding is essential to support the development of algorithms with greater benefits and fewer risks to the public.

Users choose to engage with more partisan news than they are exposed to on Google Search.

If popular online platforms systematically expose their users to partisan and unreliable news, they could potentially contribute to societal issues such as rising political polarization1,2. This concern is central to the 'echo chamber'3-5 and 'filter bubble'6,7 debates, which critique the roles that user choice and algorithmic curation play in guiding users to different online information sources8-10. These roles can be measured as exposure, defined as the URLs shown to users by online platforms, and engagement, defined as the URLs selected by users. However, owing to the challenges of obtaining ecologically valid exposure data-what real users were shown during their typical platform use-research in this vein typically relies on engagement data4,8,11-16 or estimates of hypothetical exposure17-23. Studies involving ecological exposure have therefore been rare, and largely limited to social media platforms7,24, leaving open questions about web search engines. To address these gaps, we conducted a two-wave study pairing surveys with ecologically valid measures of both exposure and engagement on Google Search during the 2018 and 2020 US elections. In both waves, we found more identity-congruent and unreliable news sources in participants' engagement choices, both within Google Search and overall, than they were exposed to in their Google Search results. These results indicate that exposure to and engagement with partisan or unreliable news on Google Search are driven not primarily by algorithmic curation but by users' own choices.

Access to Immediately Available Balanced Blood Products in a Rural State's Trauma System.

INTRODUCTION: The Arkansas Trauma System was established by law more than a dozen years ago, and all participating trauma centers are required to maintain red blood cells. Since then, there has been a paradigm shift in resuscitating exsanguinating trauma patients. Damage Control Resuscitation with balanced blood products (or whole blood) and minimal crystalloid is now the standard of care. This project aimed to determine access to balanced blood products in our state's Trauma System (TS). METHODS: A survey of all trauma centers in the Arkansas TS was conducted, and geospatial analysis was performed. Immediately Available Balanced Blood (IABB) was defined as at least 2 units (U) of thawed plasma (TP) or never frozen plasma (NFP), 4 units of red blood cells (RBCs), 2 units of fresh frozen plasma (FFP), and 1 unit of platelets or 2 units of whole blood (WB). RESULTS: All 64 trauma centers in the state TS completed the survey. All level I, II, and III Trauma Centers (TCs) maintain RBC, plasma, and platelets, but only half of the level II and 16% of the level III TCs have thawed or never frozen plasma. A third of level IV TCs maintain only RBCs, while only 1 had platelets, and none had thawed plasma. 85% of people in our state are within 30 min of RBCs, almost two-thirds are within 30 min of plasma (TP, NFP, or FFP) and platelets, while only a third are within 30 min of IABB. More than 90% are within an hour of plasma and platelets, while only 60% are within that time from an IABB. The median drive times for Arkansas from RBC, plasma (TP, NFP, or FFP), platelets, and an immediately available and balanced blood bank are 19, 21, 32, and 59 minutes, respectively. A lack of thawed or non-frozen plasma and platelets are the most common limitations of IABB. One level III TC in the state maintains WB, which would alleviate the limited access to IABB. CONCLUSION: Only 16% of the trauma centers in Arkansas can provide IABB, and only 61% of the population can reach IABB within 60 minutes. Opportunities exist to reduce the time to balanced blood products by selectively distributing WB, TP, or NFP to hospitals in our state trauma system.

Retrospective study on rib fractures: smoking and alcohol matter for mortality and complications.

BACKGROUND: Rib fractures and substance use are both common in trauma patients, but there is little data on how smoking and alcohol use may be associated with outcomes in these patients. We assessed the association between smoking or alcohol use disorder (AUD) and outcomes in patients with rib fractures. METHODS: We used institutional databases to conduct a retrospective review of patients with rib fractures at the only American College of Surgeons-verified adult level 1 trauma center in a rural state between 2015 and 2019. The key exposure variables were smoking and AUD. The key outcome variables were mortality and pulmonary complications (pneumonia, adult respiratory distress syndrome, and pneumothorax). We used multivariable regression for analysis and directed acyclic graphs to identify variables for adjustment. RESULTS: We identified 1880 eligible patients with rib fractures, including 693 (37%) who were smokers and 204 (11%) who had AUD. Compared with non-smokers, smokers were younger, more often male, and had lower mortality rates. Regression showed that smokers had a lower likelihood of mortality (OR 0.48; 95% CI 0.27 to 0.87; p=014). Likelihood of pneumonia, ARDS, and pneumothorax was not different between smokers and non-smokers. Compared with patients without AUD, patients with AUD were older, more often male, and had higher likelihood of pneumonia and lower likelihood of pneumothorax. Regression showed that patients with AUD had higher likelihood of pneumonia (OR 1.82; 95% CI 1.24 to 2.68; p=0.002) and lower likelihood of pneumothorax (OR 0.51; 95% CI 0.33 to 0.75; p=0.002). DISCUSSION: In trauma patients with rib fractures treated at a level 1 trauma center over 5 years, smoking was associated with decreased risk of mortality. These findings have implications for risk stratification and clinical decision-making for patients with rib fractures. LEVEL OF EVIDENCE: III.

Hemorrhage-Control Training in Medical Education.

OBJECTIVES: To evaluate and analyze the efficacy of implementation of hemorrhage-control training into the formal medical school curriculum. We predict this training will increase the comfort and confidence levels of students with controlling major hemorrhage and they will find this a valuable skill set for medical and other healthcare professional students. METHODS: After IRB and institutional approval was obtained, hemorrhage-control education was incorporated into the surgery clerkship curriculum for 96 third-year medical students at the University of Arkansas for Medical Sciences using the national Stop The Bleed program. Using a prospective study design, participants completed pre- and post-training surveys to gauge prior experiences and comfort levels with controlling hemorrhage and confidence levels with the techniques taught. Course participation was mandatory; survey completion was optional. The investigators were blinded as to the individual student's survey responses. A knowledge quiz was completed following the training. RESULTS: Implementation of STB training resulted in a significant increase in comfort and confidence among students with all hemorrhage-control techniques. There was also a significant difference in students' perceptions of the importance of this training for physicians and other allied health professionals. CONCLUSION: Hemorrhage-control training can be effectively incorporated into the formal medical school curriculum via a single 2-hour Stop The Bleed course, increasing students' comfort level and confidence with controlling major traumatic bleeding. Students value this training and feel it is a beneficial addition to their education. We believe this should be a standard part of undergraduate medical education.

Impact of Palliative Care Utilization for Surgical Patients Receiving Prolonged Mechanical Ventilation: National Trends (2009-2013).

BACKGROUND: Patients requiring mechanical ventilation (MV) have high morbidity and mortality. Providing palliative care has been suggested as a way to improve comprehensive management. The objective of this retrospective cross-sectional study was to identify predictors for palliative care utilization and the association with hospital length of stay (LOS) among surgical patients requiring prolonged MV (≥ 96 consecutive hours). METHODS: National Inpatient Sample (NIS) data 2009-2013 was used to identify adults (age ≥ 18) who had a surgical procedure and required prolonged MV (≥ 96 consecutive hours), as well as patients who also had a palliative care encounter. Outcomes were palliative care utilization and association with hospital LOS. RESULTS: Utilization of palliative care among surgical patients with prolonged MV increased yearly, from 5.7% in 2009 to 11.0% in 2013 (p < 0.001). For prolonged MV surgical patients who died, palliative care increased from 15.8% in 2009 to 33.2% in 2013 (p < 0.001). Median hospital LOS for patients with and without palliative care was 16 and 18 days, respectively (p < 0.001). Patients discharged to either short or long term care facilities had a shorter LOS if palliative care was provided (20 vs. 24 days, p < 0.001). Factors associated with palliative care utilization included older age, malignancy, and teaching hospitals. Non-Caucasian race was associated with less palliative care utilization. CONCLUSIONS: Among surgical patients receiving prolonged MV, palliative care utilization is increasing, although it remains low. Palliative care is associated with shorter hospital LOS for patients discharged to short or long term care facilities.

Paradoxical embolism through PFO leading to stroke in a gunshot victim with IVC injury.

A 23-year-old man presented to the emergency department with multiple gunshot wounds to the chest and abdomen, and was taken to the operating room emergently for exploratory laparotomy due to hemodynamic instability. The patient underwent inferior vena cava (IVC), bowel and ureter repair during the procedure, requiring massive amounts of blood products. The patient transferred to the surgical intensive care unit with a routine post-operative course for approximately the next 7 days before presenting with signs of stroke. The patient was diagnosed with deep vein thrombosis in IVC at the repair site on a follow-up venogram. Upon further work-up with echocardiography, the patient was determined to have a patent foramen ovale (PFO), with paradoxical embolism as the most likely cause of the stroke. We present this unusual case of a GSW leading to stroke due to embolism from a venous source through a PFO.

Right external iliac artery thrombus following the use of resuscitative endovascular balloon occlusion of the aorta for placenta accreta.

A 33-year-old female, 32 weeks and 1 day gestation, with known placenta accreta who presented to the emergency department with 2 h of severe abdominal pain, nausea and vomiting. She became hypotensive and underwent emergency cesarean section. Emergency general surgery was consulted for placement of a resuscitative endovascular balloon for aortic occlusion (REBOA). After successful delivery, the balloon was inflated in zone 3 and systolic blood pressure rose from 70 to 170 mmHg. The patient underwent hysterectomy for ongoing hemorrhage. The patient was taken to the surgical intensive care unit. The patient was noted to have pulses following removal of the sheath. Arterial brachial indices and arterial duplex was performed 48 h after sheath removal. The patient was found to have complete occlusion of the right external iliac artery. Vascular surgery was consulted and cut-down performed with thrombus removal via fogarty catheter. The patient was discharged 2 days later without further complication.

Morning report decreases length of stay in trauma patients.

BACKGROUND: Modern acute care surgery (ACS) programs depend on consistent patient hand-offs to facilitate care, as most programs have transitioned to shift-based coverage. We sought to determine the impact of implementing a morning report (MR) model on patient outcomes in the trauma service of a tertiary care center. METHODS: The University of Arkansas for Medical Sciences (UAMS) Division of ACS implemented MR in October 2015, which consists of the trauma day team, the emergency general surgery day team, and a combined night float team. This study queried the UAMS Trauma Registry and the Arkansas Clinical Data Repository for all patients meeting the National Trauma Data Bank inclusion criteria from January 1, 2011 to April 30, 2018. Bivariate frequency statistics and generalized linear model were run using STATA V.14.2. RESULTS: A total of 11 253 patients (pre-MR, n=6556; post-MR, n=4697) were analyzed in this study. The generalized linear model indicates that implementation of MR resulted in a significant decrease in length of stay (LOS) in trauma patients. DISCUSSION: This study describes an approach to improving patient outcomes in a trauma surgery service of a tertiary care center. The data show how an MR session can allow for patients to get out of the hospital faster; however, broader implications of these sessions have yet to be studied. Further work is needed to describe the decisions being made that allow for a decreased LOS, what dynamics exist between the attendings and the residents in these sessions, and if these sessions can show some of the same benefits in other surgical services. LEVEL OF EVIDENCE: Level 4, Care Management.

When Minutes Fly by: What Is the True "Golden Hour" for Air Care?

Air transport was developed to hasten patient transport based on the "golden hour" belief that delayed care leads to poorer outcome. The primary aim of our study was to identify the critical inflection point of increased nonsurvivors on total prehospital time. This was a multicenter review of adult trauma patients transported by air between November 2014 and August 2015. Primary outcome of interest was all-cause inhospital mortality. Total helicopter emergency medical services times of nonsurvivors were plotted to visualize the distribution of prehospital time. Of 636 patients included, 71 per cent were male and 86 per cent suffered blunt trauma. Among nonsurvivors, mortality doubled once total helicopter emergency medical services time exceeded 30 minutes (P < 0.001). Nonsurvivors presented with significantly lower median [interquartile range (IQR)] Glasgow Coma Score compared with survivors [3 (3-13) vs 15 (12-15), respectively; P < 0.001] as well as a significantly higher median (IQR) Injury Severity Score [26 (19-41) vs 12 (5-22); P < 0.001], increased incidence of penetrating mechanism of injury [21 vs 8%; P = 0.002], and higher median (IQR) shock index [0.84 (0.63-1.06) vs 0.71 (0.6-0.87); P = 0.023]. We identified an inflection point of doubling in mortality after 30 minutes. This suggests a possible threshold effect between time and mortality in severely injured patients. Revised field criteria for determining which injured patients would most benefit from helicopter transport are needed.

Dilated cardiomyopathy secondary to acute pancreatitis caused by hypertriglyceridemia.

A 30-year-old male presented to an outside facility with acute pancreatitis and triglycerides of 1594. He was transferred to our facility after becoming febrile, hypoxic and in acute renal failure with triglycerides of 4243. CT scan performed showed wall-off pancreatic necrosis. He underwent continuous renal replacement therapy and his acute renal failure resolved. He was treated with broad spectrum antibiotics and discharged. He developed a fever to 101 a week later and was found to have a large infected pancreatic pseudocyst. This was managed with an IR placed drain. This was continued for 6 weeks. He came to the emergency department several weeks later with shortness of breath and 3+ edema to bilateral lower extremities and lower abdomen. TTE performed showed an EF of 15%. He was diuresed 25 L during that stay. His heart failure was medically managed. We present this case of dilated cardiomyopathy secondary to acute pancreatitis.

Estimates of Non-Heterosexual Prevalence: The Roles of Anonymity and Privacy in Survey Methodology.

When do people feel comfortable enough to provide honest answers to sensitive questions? Focusing specifically on sexual orientation prevalence-a measure that is sensitive to the pressures of heteronormativity-the present study was conducted to examine the variability in U.S. estimates of non-heterosexual identity prevalence and to determine how comfortable people are with answering questions about their sexual orientation when asked through commonly used survey modes. We found that estimates of non-heterosexual prevalence in the U.S. increased as the privacy and anonymity of the survey increased. Utilizing an online questionnaire, we rank-ordered 16 survey modes by asking people to rate their level of comfort with each mode in the context of being asked questions about their sexual orientation. A demographically diverse sample of 652 individuals in the U.S. rated each mode on a scale from -5 (very uncomfortable) to +5 (very comfortable). Modes included anonymous (name not required) and non-anonymous (name required) versions of questions, as well as self-administered and interviewer-administered versions. Subjects reported significantly higher mean comfort levels with anonymous modes than with non-anonymous modes and significantly higher mean comfort levels with self-administered modes than with interviewer-administered modes. Subjects reported the highest mean comfort level with anonymous online surveys and the lowest with non-anonymous personal interviews that included a video recording. Compared with the estimate produced by an online survey with a nationally representative sample, surveys utilizing more intrusive methodologies may have underestimated non-heterosexual prevalence in the U.S. by between 50 and 414%. Implications for public policy are discussed.

Does the Institution of a Statewide Trauma System Reduce Preventable Mortality and Yield a Positive Return on Investment for Taxpayers?

BACKGROUND: In July 2009, Arkansas began to annually fund $20 million for a statewide trauma system (TS). We studied injury deaths both pre-TS (2009) and post-TS (2013 to 2014), with attention to causes of preventive mortality, societal cost of those preventable mortality deaths, and benefit to tax payers of the lives saved. STUDY DESIGN: A multi-specialty trauma-expert panel met and reviewed records of 672 decedents (290 pre-TS and 382 post-TS) who met standardized inclusion criteria, were judged potentially salvageable, and were selected by a proportional sampling of the roughly 2,500 annual trauma deaths. Deaths were adjudicated into sub-categories of nonpreventable and preventable causes. The value of lives lost was calculated for those lives potentially saved in the post-TS period. RESULTS: Total preventable mortality was reduced from 30% of cases pre-TS to 16% of cases studied post-TS, a reduction of 14%. Extrapolating a 14% reduction of preventable mortality to the post-TS study period, using the same inclusion criteria of the post-TS, we calculate that 79 lives were saved in 2013 to 2014 due to the institution of a TS. Using a minimal standard estimate of $100,000 value for a life-year, a lifetime value of $2,365,000 per person was saved. This equates to an economic impact of the lives saved of almost $186 million annually, representing a 9-fold return on investment from the $20 million of annual state funding invested in the TS. CONCLUSIONS: The implementation of a TS in Arkansas during a 5-year period resulted in a reduction of the preventable death rate to 16% post-TS, and a 9-fold return on investment by the tax payer. Additional life-saving gains can be expected with ongoing financial support and additional system performance-improvement efforts.

Use of a Novel Accounting and Grouping Method for Major Trunk Injury-Analysis of Data from a Statewide Trauma Financial Survey.

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

Management of Pneumatosis Intestinalis in a Pediatric Burn Patient.

Pneumatosis intestinalis is gas in the wall of the gastrointestinal tract. It is not well described in pediatric burn patients. The authors present the case of a 23-month-old girl who sustained 40% total body surface area deep-partial and full-thickness burns as well as a grade two inhalational injury. On postburn day two, radiographic imaging showed extensive pneumatosis of the colon. She was managed with bowel rest, broad-spectrum antibiotics, and parenteral nutrition. Radiographic resolution of pneumatosis intestinalis occurred several days later and was followed by reinitiation of enteral feeds and bowel function. The patient later developed an abscess and a subsequent colocutaneous fistula that resolved with percutaneous drainage and conservative management. She healed and was able to avoid a laparotomy with possible bowel resection.

The search engine manipulation effect (SEME) and its possible impact on the outcomes of elections.

Internet search rankings have a significant impact on consumer choices, mainly because users trust and choose higher-ranked results more than lower-ranked results. Given the apparent power of search rankings, we asked whether they could be manipulated to alter the preferences of undecided voters in democratic elections. Here we report the results of five relevant double-blind, randomized controlled experiments, using a total of 4,556 undecided voters representing diverse demographic characteristics of the voting populations of the United States and India. The fifth experiment is especially notable in that it was conducted with eligible voters throughout India in the midst of India's 2014 Lok Sabha elections just before the final votes were cast. The results of these experiments demonstrate that (i) biased search rankings can shift the voting preferences of undecided voters by 20% or more, (ii) the shift can be much higher in some demographic groups, and (iii) search ranking bias can be masked so that people show no awareness of the manipulation. We call this type of influence, which might be applicable to a variety of attitudes and beliefs, the search engine manipulation effect. Given that many elections are won by small margins, our results suggest that a search engine company has the power to influence the results of a substantial number of elections with impunity. The impact of such manipulations would be especially large in countries dominated by a single search engine company.