Evaluating Inpatient Hospital Charges Associated With Trauma Service Patients Participating in an Accountable Care Organization.

Background: The Medicare Accountable Care Organization (ACO) Program has created a vehicle for providers who practice cost containment and exceed quality for the Medicare population. The success of ACO's nationwide have been well documented. However, there is little research evaluating if there is a cost saving benefit in trauma care with respect to participating in an ACO. Thus, the primary objective of this study was to evaluate inpatient hospital charges associated with trauma service utilization of patients participating in the ACO compared to non-ACO patients. Methods: This case-control retrospective study includes a comparison of inpatients charges of ACO patients (cases) and general trauma patients (controls) presenting to our trauma center in Staten Island, New York from January 1st, 2019 to December 31st, 2021. A 1:1 matching of case to control was performed based on age, sex, race, and injury severity score. Statistical analysis was performed with IBM SPSS, with P < .05 as significant. Results: A total of 80 patients were included in the ACO cohort and 80 matched in the General Trauma cohort. Patient demographics were similar. Comorbidities were similar with the exception of a higher in incidence of hypertension (75.0% vs 47.5%, P < .001) and cardiac disease (35.0% vs 17.5%, P = .012) in the ACO cohort. Both the ACO and general trauma cohort had similar Injury Severity Scores, number of visits and lenght of stay. Both charge total ($76 148.93 vs $70 916.82, P = .630) receipt total ($15 080.26 vs $14 180, P = .662) charges were similar between ACO and General Trauma patients. Conclusion: In spite of increased incidence of hypertension and cardiac disease in ACO trauma patients, mean Injury Severity Score, number of visits, length of hospital stay, ICU admission rate and charge total was similar compared to general trauma patients presenting to our Level 1 Adult Trauma Center.

Multinomial Estimations of Predictive Risk Factors for Traumatic Brain Injuries.

Introduction Traumatic brain injuries (TBIs) affect millions of patients each year, with more than 220,000 hospitalizations in 2019 and 64,000 deaths in 2020 alone. TBIs span a plethora of injuries including cerebral contusions and lacerations, axonal injuries, optic pathway disruptions, and skull fractures. Previous research has established that characteristics such as sex, mechanism of injury (MOI), and blood-thinning agents have some causal connections to a variety of cranial traumas. Methods This paper sought to analyze aggravating risk factors for various TBIs in the New York City borough of Staten Island. Data on eight predictive risk variables were collected at a level 1 trauma center from January 1, 2022, to December 31, 2022: MOI, seizure history, anticoagulant/antiplatelet therapy, alcoholism, age, biological sex, tested alcohol level, and body mass index (BMI). A multinomial logistic regression was estimated to generate risk ratios (RRs), and chi-squared tests were carried out to determine univariate associations. Results It was found that blood thinner use and sex were both significant predictors of various types of TBIs. Additionally, those not tested for alcohol, including pediatric patients, were less likely to suffer most forms of TBI, while BMI had a negligible relationship with any TBI class. The use of blood-thinning agents put patients at an increased risk of concussions (relative risk ratio [RRR]: 1.82; 95% confidence interval [CI]: 1.10-3.02) and undiagnosed intracranial injuries (RRR: 1.90; 95% CI: 1.08-3.34). Men were at higher risk of multiple cranial injuries than women (RRR: 3.62; 95% CI: 1.38-9.48), as well as physical traumas such as brain lacerations and hemorrhages (RRR: 2.81, 95% CI: 1.28-6.18). BMI was weakly correlated with undiagnosed cranial injuries (RRR: 1.04; 95% CI: 1.00-1.08) and slightly uncorrelated with physical traumas (RRR: 0.94; 95% CI: 0.88-1.00). Those not tested for alcohol were at far less risk of multiple TBIs (RRR: 0.08; 95% CI: 0.01-0.66), concussions (RRR: 0.27; 95% CI: 0.11-0.71), and physical brain traumas (RRR: 0.33; 95% CI: 0.13-0.84). No parameter exhibited any statistical significance with skull fractures. Conclusion Particular risk factors for TBIs include biological sex and blood thinner use. Injury prevention efforts should be based on the category of TBI, with a particular focus on blood thinner users becoming concussive post-trauma. Attention should also be paid to men who engage in risky behavior such as binge drinking and crime sustaining more than one brain trauma or isolated brain bleeds. Therefore, improved hospital outreach for fall precautions in nursing homes and targeted interventions for at-risk men are vital for future projects.

Outcome of bile leakage following liver resection with hepaticojejunostomy for liver cancer.

We aimed to investigate contemporary management and outcomes of bile leakage in patients who underwent hepatectomy with hepaticojejunostomy for liver malignancy. The NSQIP database was used to study clinical data of patients who underwent a hepatectomy with hepaticojejunostomy for a primary hepatobiliary cancer and developed bile leakage between 1/2014 and 12/2017. Multivariate regression analysis was performed to investigate outcomes. Five hundred patients underwent a hepatectomy with hepaticojejunostomy for a malignant primary hepatobiliary cancer (41% intrahepatic cholangiocarcinoma, 38.2% hilar cholangiocarcinoma, 9.8% hepatocellular carcinoma, 6% gallbladder cancer, and 5% others). The rate of bile leakage was 33.4%. Most patients (90.4%) did not require re-exploration. In 77 of 157 patients (49.1%), bile leakages were contained with intraoperatively placed drain(s) and no additional surgical intervention was required. A total of 71 patients (42.5%)-including 64 patients with intraoperative drains-required interventional radiology (IR)-guided drainage, with a 88.7% success rate. A total of 16 patients (9.6%) required re-exploration to control the leakage, with 8 of them having undergone failed IR-drainage. When running multivariate analysis, post-hepatectomy liver failure (AOR: 158.26, P < 0.01), preoperative sepsis (AOR: 36.24, P = 0.03), and smoking (AOR: 14.07, P = 0.03) were significantly associated with mortality of patients. Biliary leakage is relatively common following hepatectomy with hepaticojejunostomy for liver malignancy (33.4%), but most patients (90.4%) do not require re-exploration. Intraoperatively placed drains successfully controlled 46.7% of bile leakages. IR-guided drain placement had a 88.7% success rate for adequate leak control.

Cerebral Salt Wasting in Traumatic Brain Injury Is Associated with Increased Morbidity and Mortality.

INTRODUCTION: In the setting of cerebral injury, cerebral salt wasting (CSW) is a potential cause of hyponatremia, which contributes to adverse effects and mortality. OBJECTIVE: The primary objective of this study was to evaluate the clinical outcomes of severe traumatic brain injury (TBI) patients complicated by CSW. METHODS: A retrospective data analysis was performed on data collected from patients with TBI with an abbreviated injury scale (AIS) greater than 3. Data was divided into 2 groups of patients with CSW and those without. The primary endpoint was incidence of adverse effects of CSW in regard to injury severity score (ISS), hospital length of stay (HLOS), ventilator days, ICU length of stay (ICU LOS) and survival to discharge. Data was analyzed using a one-way analysis of variance (ANOVA). RESULTS: A total of 310 consecutive patients with severe head injury (anatomic injury score 3 or greater) were evaluated over a 3-year period. A total of 125 of the 310 patients (40%) were diagnosed with cerebral salt wasting as defined by hyponatremia with appropriate urinary output and salt replacement. Patients with CSW had poorer outcomes in regard to ISS (21.8 vs 14.2, p<0.0001), HLOS (14.1 vs 3.5, p<0.0001), ventilator days (5.0 vs 0.45, p<0.0001), ICU LOS (8.5 vs 1.6, p<0.0001), and survival to discharge (88% vs 99%, p<0.0001). DISCUSSION: Common adverse effects of CSW were noted in this study. Patients with TBI have a predilection towards development of CSW and consequently have poorer outcomes including increased morbidity and mortality. Data is sparse on the duration of CSW and degree of hyponatremia over time. Larger, comparative studies need to be performed to investigate the hyponatremic patient population and the clinical outcomes of those who present with CSW.

Pulmonary Hygiene Protocol Reduces Incidence of Lobar Collapse in Severe Traumatic Brain Injury.

Background Traumatic brain injury (TBI) is a common cause of death among injured patients. In addition to neurologic sequelae which may increase mortality risk, trauma patients suffering severe TBI (Glasgow Coma Score≤8) have a predilection for pulmonary complications. We have previously demonstrated that patients with severe TBI who were intubated and mechanically ventilated are at greater risk of radiographic pulmonary lobar collapse that necessitates advanced directional suctioning and/or bronchoscopy. We sought to minimize the potentially deleterious effects of such lobar collapse by using a standardized pulmonary hygiene protocol. Methods We performed a retrospective comparison of lobar collapse incidence among three groups over 21 months: patients without severe TBI who were intubated and mechanically ventilated for greater than 24 hours (i.e. "NO TBI"); patients with severe TBI who were intubated and mechanically ventilated for greater than 24 hours who were not treated with a standardized pulmonary hygiene protocol (i.e. historical "CONTROL"); and patients with severe TBI who were intubated and mechanically ventilated for greater than 24 hours and who were treated with a standardized pulmonary hygiene protocol (i.e. "HYGIENE"). Our analysis excluded patients who had any significant neck injury as we had previously found that pulmonary complications are increased in this subpopulation. Results We reviewed the charts of 310 trauma patients (NO TBI = 104, CONTROL = 101, HYGIENE = 105) and analyzed demographics, injury severity and outcomes, including the incidence of pulmonary lobar collapse. Pulmonary hygiene protocol demonstrated a significant reduction in the incidence of lobar collapse among the HYGIENE group compared to CONTROL, approximating the incidence among patients with no TBI (11% vs 27% vs 10%, respectively, p = 0.0009). No significant difference was noted in ventilator days, intensive care unit length of stay, hospital length of stay, mortality, nor incidence of pneumonia.  Conclusion High-risk TBI patients have a predilection towards the development of pulmonary lobar collapse, which can be significantly reduced by the use of a standardized pulmonary hygiene protocol.

Value of the pretreatment albumin to globulin ratio in predicting long-term mortality in breast cancer patients.

BACKGROUND: Prior studies have demonstrated the prognostic value of pretreatment serum albumin in different types of cancer. The aim of this study was to assess the predictive value of the albumin to globulin ratio (AGR) on survival in breast cancer patients. METHODS: This retrospective study used an unselected cohort of 354 breast cancer patients who had documented total protein and albumin levels prior to chemotherapy. Survival status was obtained from our cancer registry. Survival analysis, stratified by AGR tertiles, was used to evaluate the prognostic value of AGR. RESULTS: Patients in the highest AGR tertiles (AGR > 1.45) had a lower 5-year mortality rate compared with those in the middle (AGR 1.21 to 1.45) and the lowest (AGR < 1.21) tertiles (6% vs. 18% and 32%, P < .001). After adjusting for confounding variables, AGR remained a significant predictor of mortality (P < .002). Moreover, after excluding the patients with albumin levels less than 3.6, the AGR remained a significant predictor of survival (P .0018). CONCLUSIONS: Pretreatment AGR is an independent, significant predictor of long-term mortality in breast cancer patients, even in patients with normal albumin levels.

Epinephrine-induced posterior reversible encephalopathy syndrome: a case report.

Posterior reversible encephalopathy syndrome (PRES) is a rare disorder that is usually associated with hypertensive crises. It is often missed but may be diagnosed by head computed tomographic (CT) scan or magnetic resonance imaging. An adolescent man presented for elective right shoulder arthroscopic bankart repair. Arthroscopy was performed using a solution of normal saline with 3.3 mg/L of epinephrine for irrigation. Postoperatively, the patient presented with hypertension and epileptiform activity. A CT scan of the head showed PRES.