Impact of a Rounding Tool and Clinical Champion on Trauma Patient Screening, Brief Intervention, and Referral to Treatment for Alcohol Use Disorder.

BACKGROUND: Early identification and treatment of alcohol misuse among trauma patients is the standard of care for trauma centers. Yet, trauma programs face significant barriers in adherence to sustained alcohol misuse screening. OBJECTIVE: This study aims to evaluate the impact of a rounding tool and clinical champion on screening, brief intervention, and referral to treatment compliance rates for alcohol use disorder in trauma patients. METHODS: This is a single-center, retrospective cohort design measuring the impact of a nursing rounding tool and clinical champion on screening, brief intervention, and referral to treatment for alcohol use disorder in trauma patients older than 14 years. Retrospective reviews were conducted over a 5-year period from 2017 to 2021 for all admitted trauma patients as defined by the National Trauma Data Standard. RESULTS: More than 5,000 trauma patients were included during the study period. The nurses' rounding tool and clinical champion intervention led to an increase in the alcohol use disorder screening rate from an average of 59% for the first 3 months of the study (May to July 2017) to 95% for the last 3 months of the study (March to May 2021). CONCLUSION: Our findings show that a dedicated clinical champion and nurse rounding tool increase compliance for screening, brief intervention, and referral to treatment for alcohol use disorder in trauma patients.

Incidence, outcomes and costs of severe sepsis and septic shock in geriatric trauma patients: Analysis of 2,563,463 hospitalizations at 3,284 hospitals.

BACKGROUND: Severe sepsis/septic shock (sepsis) is a leading cause of death in hospitalized trauma patients. Geriatric trauma patients are an increasing proportion of trauma care but little recent, large-scale, research exists in this high-risk demographic. The objectives of this study are to identify incidence, outcomes and costs of sepsis in geriatric trauma patients. METHODS: Patients at short-term, nonfederal hospitals 65 years or older with ≥1 injury International Classification of Diseases, Tenth Revision, Clinical Modification code were selected from 2016 to 2019 Centers for Medicare & Medicaid Services Medicare Inpatient Standard Analytical Files. Sepsis was defined as International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes R6520 and R6521. A log-linear model was used to examine the association of Sepsis with mortality, adjusting for age, sex, race, Elixhauser score, and Injury Severity Score. Dominance analysis using logistic regression was used to determine the relative importance of individual variables in predicting Sepsis. Institutional review board exemption was granted for this study. RESULTS: There were 2,563,436 hospitalizations from 3,284 hospitals (62.8% female; 90.4% White; 72.7% falls; median ISS, 6.0). Incidence of Sepsis was 2.1%. Sepsis patients had significantly worse outcomes. Mortality risk was significantly higher in septic patients (adjusted risk ratio, 3.98, 95% confidence interval, 3.92-4.04). Elixhauser score contributed the most to the prediction of Sepsis, followed by ISS (McFadden's R2 = 9.7% and 5.8%, respectively). CONCLUSION: Severe sepsis/septic shock occurs infrequently among geriatric trauma patients but is associated with increased mortality and resource utilization. Pre-existing comorbidities influence Sepsis occurrence more than Injury Severity Score or age in this group, identifying a population at high risk. Clinical management of geriatric trauma patients should focus on rapid identification and prompt aggressive action in high-risk patients to minimize the occurrence of sepsis and maximize survival. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Acute Kidney Injury: Iterative Development of an Audit Tool for Trauma Patients.

BACKGROUND: Acute kidney injury is a low-volume, high-risk complication in trauma patients and is associated with prolonged hospital length of stay and increased mortality. Yet, no audit tools exist to evaluate acute kidney injury in trauma patients. OBJECTIVE: This study aimed to describe the iterative development of an audit tool to evaluate acute kidney injury following trauma. METHODS: Our performance improvement nurses developed an audit tool to evaluate acute kidney injury in trauma patients using an iterative, multiphase process conducted from 2017 to 2021, which included a review of our Trauma Quality Improvement Program data, trauma registry data, literature review, multidisciplinary consensus approach, retrospective and concurrent review, and continuous audit and feedback for piloted and finalized versions of the tool. RESULTS: The final acute kidney injury audit tool can be completed within 30 min using data obtained from the electronic medical record and consists of six sections, including identification criteria, source potential causes, source treatment, acute kidney injury treatment, dialysis indications, and outcome status. CONCLUSION: The iterative development and testing of an acute kidney injury audit tool improved the uniform data collection, documentation, audit, and feedback of best practices to positively impact patient outcomes.

Survey of Diagnostic and Management Practices in Small Bowel Obstruction: Individual and Generational Variation Despite Practice Guidelines.

Background: Small bowel obstruction (SBO) is a common disorder managed by surgeons. Despite extensive publications and management guidelines, there is no universally accepted approach to its diagnosis and management. We conducted a survey of acute care surgeons to elucidate their SBO practice patterns.Methods: A self-report survey of SBO diagnosis and management practices was designed and distributed by email to AAST surgeons who cared for adult SBO patients. Responses were analyzed with descriptive statistics and Chi-square test of independence at α = .05.Results: There were 201 useable surveys: 53% ≥ 50 years, 77% male, 77% at level I trauma centers. Only 35.8% reported formal hospital SBO management guidelines. Computed tomography (CT) scan was the only diagnostic exam listed as "essential" by the majority of respondents (82.6%). Following NG decompression, 153 (76.1%) would "always/frequently" administer a water-soluble contrast challenge (GC). There were notable age differences in approach. Compared to those ≥50 years, younger surgeons were less likely to deem plain abdominal films as "essential" (16.0% vs 40.2%; P < .01) but more likely to require CT scan (88.3% vs 77.6%; P = .045) for diagnosis and to "always/frequently" administer GC (84.0% vs 69.2%; P < .01). Younger surgeons used laparoscopy "frequently" more often than older surgeons (34.0% vs 21.5%, P = .05).Discussion: There is significant variation in diagnosis and management of SBO among respondents in this convenience sample, despite existing PMGs. Novel age differences in responses were observed, which prompts further evaluation. Additional research is needed to determine whether variation in practice patterns is widespread and affects outcomes.

Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use.

STUDY OBJECTIVE: Evaluate the utility of routine rescanning of older, mild head trauma patients with an initial negative brain computed tomography (CT), who is on a preinjury antithrombotic (AT) agent by assessing the rate of delayed intracranial hemorrhage (dICH), need for surgery, and attributable mortality. METHODS: Participating centers were trained and provided data collection instruments per institutional review board-approved protocols. Data were obtained from manual chart review and electronic medical record download. Adults ≥55 years seen at Level I/II Trauma Centers, between 2017 and 2019 with suspected head trauma, Glasgow Coma Scale 14 to 15, negative initial brain CT, and no other Abbreviated Injury Scale injuries >2 were identified, grouped by preinjury AT therapy (AT- or AT+) and compared on dICH rate, need for operative neurosurgical intervention, and attributable mortality using univariate analysis (α=.05). RESULTS: A total of 2,950 patients from 24 centers were enrolled; 280 (9.5%) had a repeat brain CT. In those rescanned, the dICH rate was 15/126 (11.9%) for AT- and 6/154 (3.9%) in AT+. Assuming nonrescanned patients did not suffer clinically meaningful dICH, the dICH rate would be 15/2001 (0.7%) for AT- and 6/949 (0.6%) for AT+. No surgical operations were done for dICH. All-cause mortality was 9/2950 (0.3%) and attributable mortality was 1/2950 (0.03%). The attributable death was an AT+, dICH patient whose family declined intervention. CONCLUSION: In older patients with an initial Glasgow Coma Scale of 14 to 15 and a negative initial brain CT scan, the dICH rate is low (<1%) and of minimal clinical consequence, regardless of AT use. In addition, no patient had operative neurosurgical intervention. Therefore, routine rescanning is not supported based on the results of this study.

The burden of geriatric traumatic brain injury on trauma systems: Analysis of 348,800 Medicare inpatient claims.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability in older adults. The aim of this study was to characterize the burden of TBI in older adults by describing demographics, care location, diagnoses, outcomes, and payments in this high-risk group. METHODS: Using 2016-2019 Centers for Medicare & Medicaid Services (CMS) Inpatient Standard Analytical Files (IPSAF), patients >65 years with TBI (>1 injury ICD-10 starting with "S06") were selected. Trauma center levels were linked to the IPSAF file via American Hospital Association Hospital Provider ID and fuzzy-string matching. Patient variables were compared across trauma center levels. RESULTS: Three hundred forty-eight thousand eight hundred inpatients (50.4% female; 87.1% white) from 2963 US hospitals were included. Level I/II trauma centers treated 66.9% of patients; non-trauma centers treated 21.5%. Overall inter-facility transfer rate was 19.2%; in Level I/II trauma centers transfers-in represented 23.3% of admissions. Significant TBI (Head AIS ≥3) was present in 70.0%. Most frequent diagnoses were subdural hemorrhage (56.6%) and subarachnoid hemorrhage (30.6%). Neurosurgical operations were performed in 10.9% of patients and operative rates were similar regardless of center level. Total unadjusted mortality for the sample was 13.9%, with a mortality of 8.1% for those who expired in-hospital, and an additional 5.8% for those discharged to hospice. Medicare payments totaled $4.91B, with the majority (73.4%) going to Level I/II trauma centers. CONCLUSIONS: This study fills a gap in TBI research by demonstrating that although the majority of older adult TBI patients in the United States receive care at Level I/II trauma centers, a substantial percentage are managed at other facilities, despite 1 in 10 requiring neurosurgical operation regardless of level of trauma center. This analysis provides preliminary data on the function of regionalized trauma care for older adult TBI care. Future studies assessing the efficacy of early care guidelines in this population are warranted.

The FAK scaffold inhibitor C4 disrupts FAK-VEGFR-3 signaling and inhibits pancreatic cancer growth.

Even with successful surgical resection and perioperative chemotherapy and radiation, pancreatic ductal adenocarcinoma (PDA) has a high incidence of recurrence. Tumor cell survival depends on activation of signaling pathways that suppress the apoptotic stimuli of invasion and metastasis. Focal adhesion kinase (FAK) is a critical signaling molecule that has been implicated in tumor cell survival, invasion and metastasis. We have previously shown that FAK and vascular endothelial growth factor receptor 3 (VEGFR-3) are overexpressed in cancer cells and physically interact to confer a significant survival advantage. We subsequently identified a novel small molecule inhibitor C4 that targeted the VEGFR-3-FAK site of interaction. In this study, we have shown that C4 disrupted the FAK-VEGFR-3 complexes in PDA cells. C4 treatment caused dose-dependent dephosphorylation and inactivation of the VEGFR-3 and FAK, reduction in cell viability and proliferation, cell cycle arrest and apoptosis in PDA cells. C4 increased the sensitivity of tumor cells to gemcitabine chemotherapy in vitro that lead to apoptosis at nanomolar concentrations of both drugs. C4 reduced tumor growth in vivo in subcutaneous and orthotopic murine models of PDA. The drug alone at low dose, decreased tumor growth; however, concomitant administration with low dose of gemcitabine had significant synergistic effect and led to 70% tumor reduction. Combination of C4 with gemcitabine had a prolonged cytostatic effect on tumor growth after treatment withdrawal. Finally, we report an anecdotal case of stage IV pancreatic cancer treated with gemcitabine in combination with C4 that showed a significant clinical response in primary tumor and complete clinical response in liver metastasis over an eight month period. Taken together, these results demonstrate that targeting the scaffolding function of FAK with a small-molecule FAK-VEGFR-3 inhibitor can be an effective therapeutic strategy against PDA.

Pancreatic stent placement is associated with resolution of refractory grade C pancreatic fistula after left-sided pancreatectomy.

Pancreatic fistula have been a source of significant morbidity and mortality after left-sided pancreatectomy. The majority of fistulas are classified as Grade A and resolve quickly with no intervention. Grade C pancreatic fistulas, which require percutaneous or operative drainage, are less common and may be associated with morbidity and mortality. We used postoperative endoscopic pancreatic stent placement as an adjunctive strategy in the management of refractory Grade C pancreatic fistulas. Patients undergoing endoscopic pancreatic stent placement for persistent, refractory peripancreatic fluid collections/pancreatic fistula after left-sided pancreatectomy were identified. Eight patients underwent endoscopic pancreatic stent placement for refractory Grade C pancreatic fistulas. Six patients had percutaneous catheter placement; two patients had transgastric drainage. Endoscopic retrograde cholangiopancreatography (ERCP) showed extravasation of contrast from the distal end of the pancreatic duct in seven patients. Pancreatic stents were placed in all patients at a median time of 48 days postoperation and left for a median of 47 days. Before stent removal, ERCP demonstrated pancreatic fistula closure. Median time to complete resolution of the fistula was 41 days after stent placement. Endoscopic pancreatic stents were associated with resolution of Grade C fistulas. After distal pancreatectomy, pancreatic stent placement should be considered in the postoperative period for refractory pancreatic fistulas.

Vascular endothelial growth factor receptor-3 promotes breast cancer cell proliferation, motility and survival in vitro and tumor formation in vivo.

Vascular endothelial growth factor receptor-3 is a receptor tyrosine kinase that is overexpressed in some human carcinomas, but its role in tumorigenesis has not been fully elucidated. We examined VEGFR-3 expression in normal, nonneoplastic and early stage malignant breast tissues and have shown that VEGFR-3 upregulation in breast cancer preceded tumor cell invasion, suggesting that VEGFR-3 may function as a survival signal. We characterized the biological effects of VEGFR-3 over-expression in human breast cancer cells based on two approaches: gain of function by overexpressing VEGFR-3 in MCF-7 breast cancer cells and loss of function by RNAi-mediated silencing of VEGFR-3 in MCF-7-VEGFR-3 and BT474 cells. VEGFR-3 overexpression increased cellular proliferation by 40% when MCF7-VEGFR-3 cells were compared to parental MCF7 cells, and proliferation was reduced by more than 40% when endogenous VEGFR-3 was downregulated in BT474 cells. VEGFR-3 overexpression promoted a three-fold increase in motility and invasion and both motility and invasion were inhibited by downregulation of VEGFR-3. Furthermore, VEGFR-3 overexpression promoted cellular survival under stress conditions induced by staurosporine treatment and led to anchorage-independent growth. VEGFR-3 overexpression dramatically increased tumor formation in both hormone-dependent and independent xenograft models. With estrogen stimulation, MCF7-VEGFR-3 xenografts were ten times larger than control xenografts. Finally, downregulation of VEGFR-3 expression in both xenograft model cell lines led to a significant reduction of tumor growth. For the first time, we have demonstrated that VEGFR-3 overexpression promotes breast cancer cell proliferation, motility, survival, anchorage-independent growth and tumorogenicity in the absence of ligand expression.