Role of Empiric Antifungal Therapy in Patients with Perforated Peptic Ulcers

Background: It is unclear if the addition of antifungal therapy for perforated peptic ulcers (PPU) leads to improved outcomes. We hypothesized that empiric antifungal therapy is associated with better clinical outcomes in critically ill patients with PPU. Patients and Methods: The 2001-2012 Medical Information Mart for Intensive Care (MIMIC-III) database was searched for patients with PPU and the included subjects were divided into two groups depending on receipt of antifungal therapy. Propensity score matching by surgical intervention, mechanical ventilation (MV), and vasopressor administration was then performed and clinically important outcomes were compared. Multiple logistic regression was performed to calculate the odds of a composite end point (defined as "alive, hospital-free, and infection-free at 30 days"). Results: A total of 89 patients with PPU were included, of whom 52 (58%) received empiric antifungal therapy. Propensity score matching resulted in 37 pairs. On logistic regression controlling for surgery, vasopressors, and MV, receipt of antifungal therapy was not associated with higher odds (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.5-4.7; p = 0.4798) of the composite end point. Conclusions: In critically ill patients with perforated peptic ulcer, receipt of antifungal therapy, regardless of surgical intervention, was not associated with improved clinical outcomes. Selection bias is possible and therefore randomized controlled trials are required to confirm/refute causality.

The effect of mesenchymal stem cells improves the healing of burn wounds: a phase 1 dose-escalation clinical trial

Background

Stem cell therapy holds promise to improve healing and stimulate tissue regeneration after burn injury. Preclinical evidence has supported this; however, clinical studies are lacking. We examined the application of bone marrow-derived mesenchymal stem cells (BM-MSC) to deep second-degree burn injuries using a two-dose escalation protocol.

Methods

Ten individuals aged 18 years or older with deep second-degree burn wounds were enrolled. The first five patients were administered 2.5 × 10³ BM-MSC/cm² to their wounds. After safety of the initial dose level was assessed, a second group of five patients was treated with a higher concentration of 5 × 10³ allogeneic BM-MSC/cm². Safety was assessed clinically and by evaluating cytokine levels in mixed recipient lymphocyte/donor BM-MSC reactions (INFγ, IL-10 and TNFα). At each visit, we performed wound measurements and assessed wounds using a Patient and Observer Scar Assessment Scale (POSAS).

Results

All patients responded well to treatment, with 100% closure of wounds and minimal clinical evidence of fibrosis. No adverse reactions or evidence of rejection were observed for both dose levels. Patients receiving the first dose concentration had a wound closure rate of 3.64 cm²/day. Patients receiving the second dose concentration demonstrated a wound closure rate of 10.47 cm²/day. The difference in healing rates between the two groups was not found to be statistically significant (P = 0.17).

Conclusion

BM-MSC appear beneficial in optimising wound healing in patients with deep second-degree burn wounds. Adverse outcomes were not observed when administering multiple doses of allogeneic BM-MSC.

Lay Summary

Thermal injuries are a significant source of morbidity and mortality, constituting 5%–20% of all injuries and 4% of all deaths. Despite overall improvements in the management of acutely burned patients, morbidities associated with deeper burn injuries remain commonplace. Burn patients are too often left with significant tissue loss, scarring and contractions leading to physical loss of function and long-lasting psychological and emotional impacts.

In previous studies, we have demonstrated the safety and efficacy of administering bone marrow-derived mesenchymal stem cells (BM-MSC) to chronic wounds with substantial improvement in healing and evidence of tissue regeneration. In this report, we have examined the application of BM-MSC to deep second-degree burn injuries in patients.

The aim of the present phase I/II clinical trial was to examine the safety and efficacy of administering allogeneic BM-MSC to deep second-degree burns. We utilised two different dose levels at concentrations 2.5 × 10³ and 5 × 10³ cells/cm². Patients with deep second-degree burn wounds up to 20% of the total body surface area were eligible for treatment. Allogeneic BM-MSC were applied to burn wounds topically or by injection under transparent film dressing <7 days after injury. Patients were followed for at least six months after treatment.

Using two dose levels allowed us to gain preliminary information as to whether different amounts of BM-MSC administered to burn wounds will result in significant differences in safety/ clinical response. Once the safety and dose-response analysis were completed, we evaluated the efficacy of allogeneic stem cell therapy in the treatment of deep second-degree burn wounds.

In this study, we examined the role of allogeneic BM-MSC treatment in patients with deep second-degree burn injuries, in a dose-dependent manner. No significant related adverse events were reported. Safety was evaluated both clinically and by laboratory-based methods. Efficacy was assessed clinically through evidence of re-pigmentation, hair follicle restoration and regenerative change. While these findings are encouraging, more studies will be needed to better establish the benefit of BM-MSC in the treatment of burn injuries.

The hidden burden of unplanned readmission after emergency general surgery

BACKGROUND

There are no national studies of nonelective readmissions after emergency general surgery (EGS) diagnoses that track nonindex hospital readmission. We sought to determine the rate of overall and nonindex hospital readmissions at 30 and 90 days after discharge for EGS diagnoses, hypothesizing a significant portion would be to nonindex hospitals.

METHODS

The 2013 to 2014 Nationwide Readmissions Database was queried for all patients 16 years or older admitted with an EGS primary diagnosis and survived index hospitalization. Multivariable logistic regression identified risk factors for nonelective 30- and 90-day readmission to index and nonindex hospitals.

RESULTS

Of 4,171,983 patients, 13% experienced unplanned readmission at 30 days. Of these, 21% were admitted to a nonindex hospital. By 90 days, 22% experienced an unplanned readmission, of which 23% were to a nonindex hospital. The most common reason for readmission was infection. Publicly insured or uninsured patients accounted for 67% of admissions and 77% of readmissions. Readmission predictors at 30 days included leaving against medical advice (odds ratio [OR], 2.51 [2.47-2.56]), increased length of stay (4-7 days: OR, 1.42 [1.41-1.43]; >7 days: OR, 2.04 [2.02-2.06]), Charlson Comorbidity Index ≥2 (OR, 1.72 [1.71-1.73]), public insurance (Medicare: OR, 1.45 [1.44-1.46]; Medicaid: OR, 1.38 [1.37-1.40]), EGS patients who fell into the "Other" surgical category (OR, 1.42 [1.38-1.48]), and nonroutine discharge. Risk factors for readmission remained consistent at 90 days.

CONCLUSION

Given that nonindex hospital EGS readmission accounts for nearly a quarter of readmissions and often related to important benchmarks such as infection, current EGS quality metrics are inaccurate. This has implications for policy, benchmarking, and readmission reduction programs.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Microbial Epidemiology of Acute and Perforated Appendicitis: A Post-Hoc Analysis of an EAST Multicenter Study

BACKGROUND

There are significant practice variations in antibiotic treatment for appendicitis, ranging from short-course narrow spectrum to long-course broad-spectrum. We sought to describe the modern microbial epidemiology of acute and perforated appendicitis in adults to help inform appropriate empiric coverage and support antibiotic stewardship initiatives.

METHODS

This is a post-hoc secondary analysis of the Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) which prospectively enrolled adult patients (age ≥ 18 years) diagnosed with appendicitis between January 2017 and June 2018 across 28 centers in the United States. We included all subjects with positive microbiologic cultures during primary or secondary (rescue after medical failure) appendectomy or percutaneous drainage. Culture yield was compared between low- and high-grade appendicitis as per the AAST classification.

RESULTS

A total of 3,471 patients were included: 230 (7%) had cultures performed, and 179/230 (78%) had positive results. Cultures were less likely to be positive in grade 1 compared to grades 3, 4, or 5 appendicitis with 2/18 (11%) vs 61/70 (87%) (p < .001). Only 1 subject had grade 2 appendicitis and culture results were negative. E. coli was the most common pathogen and cultured in 29 (46%) of primary appendectomy samples, 16 (50%) of secondary, and 44 (52%) of percutaneous drainage samples.

CONCLUSION

Culturing low-grade appendicitis is low yield. E. coli is the most commonly cultured microbe in acute and perforated appendicitis. This data helps inform empiric coverage for both antibiotics alone and as an adjunct to operative or percutaneous intervention.

The Key to Combat Readiness Is a Strong Military-Civilian Partnership

INTRODUCTION

In peacetime, it is challenging for Army Forward Resuscitative Surgical Teams (FRST) to maintain combat readiness as trauma represents <0.5% of military hospital admissions and not all team members have daily clinical responsibilities. Military surgeon clinical experience has been described, but no data exist for other members of the FRST. We test the hypothesis that the clinical experience of non-physician FRST members varies between active duty (AD) and Army reservists (AR).

METHODS

Over a 3-year period, all FRSTs were surveyed at one civilian center.

RESULTS

Six hundred and thirteen FRST soldiers were provided surveys and 609 responded (99.3%), including 499 (81.9%) non-physicians and 110 (18.1%) physicians/physician assistants. The non-physician group included 69% male with an average age of 34 ± 11 years and consisted of 224 AR (45%) and 275 AD (55%). Rank ranged from Private to Colonel with officers accounting for 41%. For AD vs. AR, combat experience was similar: 50% vs. 52% had ≥1 combat deployment, 52% vs. 60% peri-deployment patient load was trauma-related, and 31% vs. 32% had ≥40 patient contacts during most recent deployment (all P > .15). However, medical experience differed for AD and AR: 18% vs. 29% had >15 years of experience in practice and 4% vs. 17% spent >50% of their time treating critically injured patients (all P < .001). These differences persisted across all specialties, including perioperative nurses, certified registered nurse anesthetists, operating room (OR) techs, critical-care nurses, emergency room (ER) nurses, licensed practical nurse (LPN), and combat medics.

CONCLUSIONS

This is the first study of clinical practice patterns in AD vs. AR, non-physician members of Army FRSTs. In concordance with previous studies of military surgeons, FRST non-physicians seem to be lacking clinical experience as well. To maintain readiness and to provide optimal care for our injured warriors, the entire FRST, not just individuals, should embed within civilian centers.

Discordance in Appendicitis Grading and the Association with Outcomes: A Post-Hoc Analysis of an EAST Multicenter Study

BACKGROUND

The American Association for the Surgery of Trauma (AAST) appendicitis severity grading criteria use independent subscales for radiologists (Rad), surgeons (Surg), and pathologists (Path). We reviewed the EAST Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database to determine rates of discordance and clinical consequences of inaccuracy.

MATERIALS AND METHODS

A confusion matrix was constructed for pairs among Rad, Surg, and Path. Accuracy was reported using chronologically latest diagnosis as gold standard. "Concordance" (C) was achieved when both agreed on the severity grade and "Discordance"(D) when they disagreed. A composite endpoint("COMP"= 30-d incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED[Emergency Department] visit, hospital readmission, and mortality) was compared between C versus D groups via χ² test with Bonferroni correction to define statistical significance(P = 0.05/9 = 0.005).

RESULTS

For each pair and diagnosis, subjects were categorized as C or D and compared for the incidence of COMP. Incidence of COMP for Surg and/or Path in C versus D: 16% versus. 26% (p = 0.006, NS by Bonferroni) for acute (A), 39% versus 33% (p = 0.39) for gangrenous (G), and 48% versus 37% (p = 0.035, NS by Bonferroni) for perforated (P). For Rad and/or Path in C versus. D: 17% versus 42% (p < 0.001) for A, 27% versus 31% (p = 0.95) for G, and 56% versus 48% (p = 0.48) for P. For C versus D: 17% versus 40% (p < 0.001) for A, 36% versus 26% (p = 0.43) for G, and 51% versus 39% (p = 0.29) for P.

CONCLUSIONS

In appendicitis treated by appendectomy, surgeons are most accurate at diagnosing acute appendicitis and least accurate at diagnosing gangrenous. Radiologists are less accurate for all categories. When the surgeon is wrong, clinical outcomes are not significantly worse. However, when the radiologist is wrong about acute appendicitis, patients have worse clinical outcomes.

Prophylactic Drainage after Appendectomy for Perforated Appendicitis in Adults: A Post Hoc Analysis of an EAST Multi-Center Study

Background: We sought to assess the efficacy of prophylactic abdominal drainage to prevent complications after appendectomy for perforated appendicitis. Methods: In this post hoc analysis of a prospective multi-center study of appendicitis in adults (≥ 18 years), we included patients with perforated appendicitis diagnosed intra-operatively. The 634 subjects were divided into groups on the basis of receipt of prophylactic drains. The demographics and outcomes analyzed were surgical site infection (SSI), intra-abdominal abscess (IAA), Clavien-Dindo complications, secondary interventions, and hospital length of stay (LOS). Multivariable logistic regression for the cumulative 30-day incidence of IAA was performed controlling for age, Charlson Comorbidity Index (CCI), antibiotic duration, presence of drains, and Operative American Association for the Surgery of Trauma (AAST) Grade. Results: In comparing the Drain (n = 159) versus No-Drain (n = 475) groups, there was no difference in the frequency of male gender (61% versus 55%; p = 0.168), weight (87.9 ± 27.9 versus 83.8 ± 23.4 kg; p = 0.071), Alvarado score (7 [6-8] versus 7 [6-8]; p = 0.591), white blood cell (WBC) count (14.8 ± 4.8 versus 14.9 ± 4.5; p = 0.867), or CCI (1 [0-3] versus 1 [0-2]; p = 0.113). The Drain group was significantly older (51 ± 16 versus 48 ± 17 years; p = 0.017). Drain use increased as AAST EGS Appendicitis Operative Severity Grade increased: Grade 3 (62/311; 20%), Grade 4 (46/168; 27%), and Grade 5 (51/155; 33%); p = 0.007. For index hospitalization, the Drain group had a higher complication rate (43% versus 28%; p = 0.001) and longer LOS (4 [3-7] versus 3 [1-5] days; p < 0.001). We could not detect a difference between the groups in the incidence of SSI, IAA, or secondary interventions. There was no difference in 30-day emergency department visits, re-admissions, or secondary interventions. Multi-variable logistic regression showed that only AAST Grade (odds ratio 2.7; 95% confidence interval7 1.5-4.7; p = 0.001) was predictive of the cumulative 30-day incidence of IAA. Conclusions: Prophylactic drainage after appendectomy for perforated appendicitis in adults is not associated with fewer intra-abdominal abscesses but is associated with longer hospital LOS. Increasing AAST EGS Appendicitis Operative Grade is a strong predictor of intra-abdominal abscess.

Heart Rate Complexity in US Army Forward Surgical Teams During Pre Deployment Training

INTRODUCTION

For trauma triage, the US Army has developed a portable heart rate complexity (HRC) monitor, which estimates cardiac autonomic input and the activity of the hypothalamic-pituitary-adrenal (HPA) axis. We hypothesize that autonomic/HPA stress associated with predeployment training in U.S. Army Forward Surgical Teams will cause changes in HRC.

MATERIALS AND METHODS

A prospective observational study was conducted in 80 soldiers and 10 civilians at the U.S. Army Trauma Training Detachment. Heart rate (HR, b/min), cardiac output (CO, L/min), HR variability (HRV, ms), and HRC (Sample Entropy, unitless), were measured using a portable non-invasive hemodynamic monitor during postural changes, a mass casualty (MASCAL) situational training exercise (STX) using live tissue, a mock trauma (MT) STX using moulaged humans, and/or physical exercise.

RESULTS

Baseline HR, CO, HRV, and HRC averaged 72 ± 11b/min, 5.6 ± 1.2 L/min, 48 ± 24 ms, and 1.9 ± 0.5 (unitless), respectively. Supine to sitting to standing caused minimal changes. Before the MASCAL or MT, HR and CO both increased to ~125% baseline, whereas HRV and HRC both decreased to ~75% baseline. Those values all changed an additional ~5% during the MASCAL, but an additional 10 to 30% during the MT. With physical exercise, HR and CO increased to >200% baseline, while HRV and HRC both decreased to 40 to 60% baseline; these changes were comparable to those caused by the MT. All the changes were P < 0.05.

CONCLUSIONS

Various forms of HPA stress during Forward Surgical Team STXs can be objectively quantitated continuously in real time with a portable non-invasive monitor. Differences from resting baseline indicate stress anticipating an impending STX whereas differences between average and peak responses indicate the relative stress between STXs. Monitoring HRC could prove useful to field commanders to rapidly and objectively assess the readiness status of troops during STXs or repeated operational missions. In the future, health care systems and regulatory bodies will likely be held accountable for stress in their trainees and/or obliged to develop wellness options and standardize efforts to ameliorate burnout, so HRC metrics might have a role, as well.

Do all cardiac surgery patients benefit from antifibrinolytic therapy?

BACKGROUND

In trauma patients, the recognition of fibrinolysis phenotypes has led to a re-evaluation of the risks and benefits of antifibrinolytic therapy (AF). Many cardiac patients also receive AF, but the distribution of fibrinolytic phenotypes in that population is unknown. The purpose of this hypothesis-generating study was to fill that gap.

METHODS

Seventy-eight cardiac surgery patients were retrospectively reviewed. Phenotypes were defined as hypofibrinolytic (LY30 <0.8%), physiologic (0.8%-3.0%), and hyperfibrinolytic (>3%) based on thromboelastogram.

RESULTS

The population was 65 ± 10-years old, 74% male, average body mass index of 29 ± 5 kg/m² . Fibrinolytic phenotypes were distributed as physiologic = 45% (35 of 78), hypo = 32% (25 of 78), and hyper = 23% (18 of 78). There was no obvious effect of age, gender, race, or ethnicity on this distribution; 47% received AF. For AF versus no AF, the time with chest tube was longer (4 [1] vs. 3 [1] days, p = .037), and all-cause morbidity was more prevalent (51% vs. 25%, p = .017). However, when these two groups were further stratified by phenotypes, there were within-group differences in the percentage of patients with congestive heart failure (p = .022), valve disease (p = .024), on-pump surgery (p < .0001), estimated blood loss during surgery (p = .015), transfusion requirement (p = .015), and chest tube output (p = .008), which highlight other factors along with AF that might have affected all-cause morbidity.

CONCLUSION

This is the first description of the prevalence of three different fibrinolytic phenotypes and their potential influence on cardiac surgery patients. The use of AF was associated with increased morbidity, but because of the small sample size and treatment allocation bias, additional confirmatory studies are necessary. We hope these present findings open the dialog on whether it is safe to administer AFs to cardiac surgery patients who are normo- or hypofibrinolytic.

Readmission for venous thromboembolism after emergency general surgery is underreported and influenced by insurance status

BACKGROUND

Prior studies of venous thromboembolism (VTE) after emergency general surgery (EGS) are not nationally representative nor do they fully capture readmissions to different hospitals. We hypothesized that different-hospital readmission accounted for a significant number of readmissions with VTE after EGS and that predictive factors would be different for same- and different-hospital readmissions.

METHODS

The 2014 Nationwide Readmissions Database was queried for nonelective EGS hospitalizations. The outcomes were readmission to the index or different hospitals within 180 days with VTE. Multivariate logistic regressions identified risk factors for readmission to index and different hospitals with VTE, reported as odds ratios with their 95% confidence intervals. Patients were excluded if during the index admission they expired, developed a VTE, had a vena cava filter placed, or did not have at least 180 days of follow-up.

RESULTS

Of 1,584,605 patients meeting inclusion criteria, 1.3% (n = 20,963) of patients were readmitted within 180 days with a VTE. Of these, 28% (n = 5,866) were readmitted to a different hospital. Predictors overall for readmission with VTE were malignancy, prolonged hospitalization, age, and being publicly insured. However, predictors for readmission to a different hospital are based on hospital characteristics, including for-profit status, or procedure type.

CONCLUSIONS

Nearly one in three readmissions with VTE after EGS occurs at a different hospital and may be missed by current quality metrics that only capture same-hospital readmission. Such metrics may underestimate for-profit hospital postoperative VTE rates relative to public and nonprofit hospitals, potentially affecting benchmarking and reimbursement. Postdischarge VTE rate is associated with insurance status. These findings have implications for policy and prevention programming design.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Electrical Burns During Fruit Harvesting

Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.

Impact of Delay in Appendectomy on the Outcome of Appendicitis: A Post Hoc Analysis of an EAST Multicenter Study

Background: Association between time-to-appendectomy and clinical outcomes is controversial with conflicting data regarding risk of perforation. The purpose of this study was to explore the associations between in-hospital delay in treatment of simple appendicitis with the incidence of complicated appendicitis discovered at appendectomy. Methods: The Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database was queried and patients with acute appendicitis diagnosed on imaging were included. Upgrade was defined as gangrenous or perforated finding at appendectomy. Time intervals from emergency department (ED) triage to appendectomy were recorded in six-hour groups. Upgrade percentage for each group was presented and rates of a composite end point (30-day incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED visit, hospital re-admission, and mortality) were compared with Bonferroni correction to determine statistical significance (p = 0.05/9 = 0.005). Results: Of 3,004 included subjects, 484 (16%) experienced upgrade at appendectomy. Upgrade rates (%, 95% confidence interval [CI]) were: group 0-6 hours, 17% (95% CI, 14-19); group 6-11 hours, 15% (95% CI, 13-17%); group 12-17 hours, 16% (95% CI, 13-19); group 18-23 hours, 17% (95% CI, 12-23); group 24-29 hours, 30% (95% CI, 20-43); and group 30+ hours, 24% (95% CI, 14-37) (p = 0.014, NS by Bonferroni). Of 484 subjects with upgrade, 200 (41%; 95% CI, 37-46) had a worse composite outcome compared with 518 (21%; CI, 19-22) of 2,520 subjects with no upgrade (p < 0.001). The upgrade group was older (49 ± 17 years vs 39 ± 16 years), had a higher Charlson comorbidity index (CCI; 1.6 ± 1.9 vs 0.7 ± 1.4) and was more likely to have positive smoking history (20% vs 14%), and prior surgery (30% vs 22%; p < 0.001). Conclusions: We propose that ≥24-hour delay from ED triage to appendectomy is not associated with increased rate of severity upgrade from simple to complicated appendicitis. When upgrade occurs, it is correlated with older age, higher CCI, smoking history, and prior surgery and is associated with worse clinical outcomes.

Acute Kidney Injury Risk in Patients Treated with Vancomycin Combined with Meropenem or Cefepime

Background: No previous studies have determined the incidence of acute kidney injury (AKI) in trauma patients treated with vancomycin + meropenem (VM) versus vancomycin + cefepime (VC). The purpose of this study was to fill this gap. Methods: A series of 99 patients admitted to an American College of Surgeons-verified level 1 trauma center over a two-year period who received VC or VM for >48 hours were reviewed retrospectively. Exclusion criteria were existing renal dysfunction or on renal replacement therapy. The primary outcome was AKI as defined by a rise in serum creatinine (SCr) to 1.5 times baseline. Multi-variable analysis was performed to control for factors associated with AKI (age, obesity, gender, length of stay [LOS], nephrotoxic agent(s), and baseline SCr), with significance defined as p < 0.05. Results: The study population was 50 ± 19 years old, 76% male, with a median LOS of 21 [range 15-39] days, and baseline SCr of 0.9 ± 0.2 mg/dL. Antibiotics, diabetes mellitus, and Injury Severity Score were independent predictors of AKI (odds ratio [OR] 4.4; 95% confidence interval [CI] 1.4-12; OR 9.3; 95% CI 1-27; OR 1.2; 95% CI 1.023-1.985, respectively). The incidence of AKI was higher with VM than VC (10/26 [38%] versus 14/73 [19.1%]; p = 0.049). Conclusions: The renal toxicity of vancomycin is potentiated by meropenem relative to cefepime in trauma patients. We recommend caution when initiating vancomycin combination therapy, particularly with meropenem.

Early Hypermetabolism is Uncommon in Trauma Intensive Care Unit Patients

BACKGROUND

Classic experiments demonstrating hypermetabolism after major trauma were performed in a different era of critical care. We aim to describe the modern posttraumatic metabolic response in the trauma intensive care unit (TICU).

METHODS

This prospective observational study enrolled TICU mechanically ventilated adults (aged ≥18) from 3/2018-2/2019. Multiple, daily resting energy expenditure (REE) measurements were recorded. Basal energy expenditure (BEE) was calculated by the Harris-Benedict equation. Hypometabolism was defined as average daily REE < 0.85*BEE and hypermetabolism defined as average daily REE > 1.15*BEE. Demographics, interventions, and clinical outcomes were abstracted. Descriptive statistics and multivariable logistical regression models evaluating demographics with the outcome variable of hypermetabolism for the first 3 days ("sustained hypermetabolism") were performed, along with group-based trajectory modeling (GBTM).

RESULTS

Fifty-five patients were analyzed: median age was 38 (28-56) years; 38 (69%) were male; body mass index (kg/m² ) was 28 (26-32); and Injury Severity Score was 27 (19-34), with (38 [71%] blunt, 8 [15%] penetrating, 7 [13%] burn) injury mechanism. Overall, 19 (35%) had hypermetabolism on day 1 ("immediate hypermetabolism"), and 11 (21%) had sustained hypermetabolism for the first 3 days. Logistic regression analysis identified penetrating mechanism (adjusted odds ratio [AOR], 16.4; 95% CI, 1.9-199.6; p = .015), burn mechanism (AOR, 11.1; 95% CI, 1.3-116.8; p =.029), and maximum temperature (AOR, 4.2; 95% CI, 1.3-20.3; p= .041) as independent predictors of sustained hypermetabolism. GBTM identified 4 nutrition phenotypes, with 2 hyperconsumptive phenotypes associated with increased risk of malnutrition at discharge.

CONCLUSION

Only a minority of injured patients is hypermetabolic in the first week after injury. Elevated temperature, penetrating mechanism, and burn mechanism are independently associated with sustained hypermetabolism. Hyperconsumptive phenotype patients are more likely to develop malnutrition during hospitalization.

Comparing Machine Learning Algorithms for Predicting Acute Kidney Injury

Prior studies have used vital signs and laboratory measurements with conventional modeling techniques to predict acute kidney injury (AKI). The purpose of this study was to use the trend in vital signs and laboratory measurements with machine learning algorithms for predicting AKI in ICU patients. The eICU Collaborative Research Database was queried for five consecutive days of laboratory measurements per patient. Patients with AKI were identified and trends in vital signs and laboratory values were determined by calculating the slope of the least-squares-fit linear equation using three days for each value. Different machine learning classifiers (gradient boosted trees [GBT], logistic regression, and deep learning) were trained to predict AKI using the laboratory values, vital signs, and slopes. There were 151,098 ICU stays identified and the rate of AKI was 5.6 per cent. The best performing algorithm was GBT with an AUC of 0.834 ± 0.006 and an F-measure of 42.96 per cent ± 1.26 per cent. Logistic regression performed with an AUC of 0.827 ± 0.004 and an F-measure of 28.29 per cent ± 1.01 per cent. Deep learning performed with an AUC of 0.817 ± 0.005 and an F-measure of 42.89 per cent ± 0.91 per cent. The most important variable for GBT was the slope of the minimum creatinine (30.32%). This study identifies the best performing machine learning algorithms for predicting AKI using trends in laboratory values in ICU patients. Early identification of these patients using readily available data indicates that incorporating machine learning predictive models into electronic medical record systems is an inevitable requisite for improving patient outcomes.

Vasopressor Use during Emergency Trauma Surgery

Most evidence suggests early vasopressor use is associated with death after trauma, but no previous study has focused on patients requiring emergency operative intervention (OR). We test the hypothesis that vasopressors are harmful in this population. Records from 746 patients requiring OR from July 2009 to March 2013 were retrospectively reviewed and stratified based on vasopressor use (epinephrine [EPI], phenylephrine, ephedrine, norepinephrine, dobutamine, vasopressin) or no vasopressor use. Vasopressors were administered to 225 patients (30%) during OR; 59 patients (8%) received multiple vasopressors. Patients who received vasopressors were older, more severely injured, had worse vital signs, and increased mortality rate (all P < 0.001). EPI was independently associated with mortality (odds ratio, 6.88; P = 0.001). If patients who received EPI were excluded, there was no difference in mortality between those who received vasopressors alone or in combination and those that did not (5 vs 6%, P = 0.523), although multiple markers of injury severity were worse. We conclude that vasopressor use is relatively common in the most severely injured patients requiring OR and is associated with mortality. EPI is most often used for cardiac arrest, whereas other vasopressors are used for their vasoconstrictive properties. This suggests that, except for EPI, vasopressors during OR are not independently associated with mortality.

National Risk Factors for Child Maltreatment after Trauma: Failure to Prevent

The purpose of this study was to identify the risk factors for hospital readmission for child maltreatment after trauma, including admissions across different hospitals nationwide. The Nationwide Readmissions Database for 2010–2014 was queried for all patients younger than 18 years admitted for trauma. The primary outcome was readmission for child maltreatment. The secondary outcome was readmission for maltreatment presenting to a hospital different than the index admission hospital. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome. There were 608,744 admissions identified and 44,569 (7.32%) involved maltreatment at the index admission. Readmission for maltreatment was found in 1,948 (0.32%) patients and 368 (18.89%) presented to a different hospital. The highest risk for readmission for maltreatment was found in patients with maltreatment identified at the index admission (odds ratios (OR) 9.48 [8.35–10.76]). The strongest risk factor for presentation to a different hospital was found with the lowest median household income quartile (OR 3.50 [2.63–4.67]). The subgroup analysis identified 647 (0.11%) children with readmission for maltreatment that was missed during the index admission. The strongest risk factor for this outcome was Injury Severity Score > 15 (OR 3.29 [2.68–4.03]). This study demonstrates that a significant portion of admissions for trauma in children and teenagers could be misrepresented as not involving maltreatment. These index admissions could be the only chance for intervention for child maltreatment. Identifying these at-risk individuals is critical to prevention efforts.

Narrow- versus Broad-Spectrum Antibiotics for Simple Acute Appendicitis Treated by Appendectomy: A Post Hoc Analysis of EAST MUSTANG Study

BACKGROUND

We sought to compare the effectiveness of narrow- versus broad-spectrum antibiotics (abx) in preventing infectious complications in adults with acute appendicitis treated with appendectomy.

METHODS

In this post hoc analysis of a prospective multicenter observational study of appendicitis in adults (≥18 y) conducted from January 2017 to June 2018, we included only patients with simple appendicitis. Subjects were grouped based on receipt of broad-spectrum or narrow-spectrum abx before and/or after appendectomy. Outcomes compared were surgical site infection, intra-abdominal abscess, secondary interventions (percutaneous drainage or operation), emergency department (ED) visits, 30-d readmission, and hospital length of stay.

RESULTS

A total of 2336 subjects were analyzed. In comparing narrow (n = 778) versus broad (n = 1558) groups, there were no differences in male sex (53% versus 54%, P = 0.704), white blood cell (13.0 ± 3.9 versus 13.4 ± 4.5, P = 0.05), Alvarado score (6 [5-7] versus 6 [5-7], P = 0.25), or Charlson comorbidity index (0 [0-1] versus 0 [0-1], P = 0.09). A total of 688 (29%) received postoperative abx, [184 (24%) narrow and 504 (32%) broad, P < 0.001] for a median 5 [2-7] d [42 (23%) narrow and 235 (47%) broad, P < 0.001]. There were no significant differences between narrow and broad groups in surgical site infection, intra-abdominal abscess, secondary interventions, ED visits, or hospital readmissions.

CONCLUSIONS

Significant practice variation in duration and spectrum of antibiotic adjunct for surgical treatment of simple acute appendicitis treatment is evident, and broad-spectrum abx did not offer clinical advantages over narrow-spectrum abx. Restriction of antibiotic spectrum should be considered, although randomized trials are required to overcome selection bias.

Hidden Readmissions after Carotid Endarterectomy and Stenting

BACKGROUND

Historically, carotid procedures incur a readmission rate of approximately 6%; however, these studies are not nationally representative and are limited to tracking only the index hospitals. We sought to evaluate a nationally representative database for readmission rates (including different hospitals) after both carotid endarterectomy (CEA) and carotid artery stenting (CAS) and determine risk factors for poor outcomes including postoperative mortality and myocardial infarction.

METHODS

This study was a retrospective analysis utilizing the 2010-2014 Nationwide Readmissions Database to query patients aged >18 years undergoing CEA or CAS. Outcomes included initial admission mortality, and 30-day readmission, including mortality and myocardial infarction (MI). Univariable analysis of 39 demographic, clinical, and hospital variables was conducted with significance set at P < 0.05. Significant variables were included in a multivariable logistic regression to identify independent risk factors for readmission. Results were weighted for national estimates.

RESULTS

There were 527,622 patients undergoing carotid procedures and 13% (n = 69,187) underwent CAS. The 30-day readmission rate was 7% (n = 35,782), and of those, 25% (n = 8,862) were readmitted to a different hospital. When controlling for other factors, CAS was a risk factor for mortality at both index admission (odds ratio [OR] 2.29 [2.11-2.49]) and 30-day readmission (OR 1.48 [1.3-1.69]) and 30-day readmissions at both index hospital (OR 1.11 [1.07-1.14]) and different hospital (OR 1.38 [1.29-1.48]). Readmission to a different hospital increased mortality risk (OR 1.45 [1.29-1.63]) but did not have an effect on MI. Postoperative infections comprised 15% of readmissions while 6% of all readmissions were for stroke.

CONCLUSIONS

Previously unreported, one in 4 readmissions after carotid procedures occur at a different hospital and this fragmentation of care could increase mortality risk after carotid procedures particularly for CAS which was also an independent risk factor for postoperative mortality and readmissions. Further validation is required to decrease unnecessary hospital after carotid procedures.

Nationwide Outcomes and Risk Factors for Reinjury After Penetrating Trauma

BACKGROUND

Previous studies have shown that a notable portion of patients who are readmitted for reinjury after penetrating trauma present to a different hospital. The purpose of this study was to identify the risk factors for reinjury after penetrating trauma including reinjury admissions to different hospitals.

METHODS

The 2010-2014 Nationwide Readmissions Database was queried for patients surviving penetrating trauma. E-codes identified patients subsequently admitted with a new diagnosis of blunt or penetrating trauma. Univariable analysis was performed using 44 injury, patient, and hospital characteristics. Multivariable logistic regression using significant variables identified risk factors for the outcomes of reinjury, different hospital readmission, and in-hospital mortality after reinjury.

RESULTS

There were 443,113 patients identified. The reinjury rate was 3.5%. Patients presented to a different hospital in 30.0% of reinjuries. Self-inflicted injuries had a higher risk of reinjury (odds ratio [OR]: 2.66, P < 0.05). Readmission to a different hospital increased risk of mortality (OR: 1.62, P < 0.05). Firearm injury on index admission increased risk of mortality after reinjury (OR: 1.94, P < 0.05).

CONCLUSIONS

This study represents the first national finding that one in three patients present to a different hospital for reinjury after penetrating trauma and have a higher risk of mortality due to this fragmentation of care. These findings have implications for quality and cost improvements by identifying areas to improve continuity of care and the implementation of penetrating injury prevention programs.

Multi-Center Outcomes of Chlorhexidine Oral Decontamination in Intensive Care Units

Background: The efficacy of oral chlorhexidine (oCHG) for decontamination in intensive care unit (ICU) patients is controversial. The purpose of this study was to evaluate the effect of oCHG decontamination on the incidence of pneumonia, sepsis, and death in ICU patients. Methods: The Philips eICU database version 2.0 was queried for patients admitted to the ICU for ≥48 hours in 2014-2015. The primary outcome of interest was death in the ICU. Secondary outcomes were a diagnosis of pneumonia or sepsis. Patients with pneumonia or sepsis diagnosed within the first 48 hours of ICU admission were excluded from the outcome analyses. Univariable analysis was performed comparing age, gender, race, severity of illness scores, hospital characteristics, and oCHG order. Multivariable logistic regression was performed using univariable results with p < 0.05. Results: Of the 64,904 patients from 186 hospitals, 22.1% (n = 14,333) had oCHG ordered. The overall mortality rate was 6.9% (n = 4,449) and the mortality rate in patients receiving oCHG was 10.6% (n = 1,518; p < 0.001). After controlling for confounding factors, oCHG remained an independent risk factor for death (odds ratio [OR] 1.25; 95% confidence interval [CI] 1.16-1.34). After excluding patients with an early diagnosis of pneumonia, the overall pneumonia incidence was 2.6% (n = 1,431) and the incidence in patients having oCHG was 4.2% (n = 517; p < 0.001). However, multivariable logistic regression revealed no significant difference in the risk of pneumonia with oCHG (OR 0.97; 95% CI 0.85-1.09). After excluding patients with an early diagnosis of sepsis, the overall rate of sepsis was 1.8% (n = 949) and for patients with oCHG, the rate was 3.3% (n = 388; p < 0.001). After controlling for other confounders, oCHG remained an independent risk factor for sepsis (OR 1.37; 95% CI 1.19-1.59). Conclusions: A chlorhexidine mouthwash order is associated with increased odds of death and sepsis without decreased odds of pneumonia in a heterogeneous cohort of ICU patients. Additional studies are needed to understand better the effect of oCHG on outcomes.

Exercise-Induced Changes in Compensatory Reserve and Heart Rate Complexity

BACKGROUND: Portable noninvasive Heart Rate Complexity (HRC) and Compensatory Reserve Measurement (CRM) monitors have been developed to triage supine combat casualties. Neither monitor has been tested in upright individuals during physical exercise. This study tests the hypothesis that exercise evokes proportional changes in HRC and CRM.METHODS: Two instruments monitored volunteers (9 civilian and 11 soldiers) from the Army Trauma Training Department (ATTD) before, during, and following physical exercise. One recorded heart rate (HR, bpm), cardiac output (CO, L · min^-1), heart rate variability (HRV, root mean square of successive differences, ms), and HRC (Sample Entropy, unitless). The other recorded HR, pulse oximetry (S_po₂, %), and CRM (%).RESULTS: Baseline HR, CO, HRV, HRC, and CRM averaged 72 ± 1 bpm, 5.6 ± 1.2 L · min^-1, 48 ± 24 ms, 1.9 ± 0.5, and 85 ± 10% in seated individuals. Exercise evoked peak HR and CO at > 200% of baseline, while HRC and CRM were simultaneously decreased to minimums that were ≤ 50% of baseline (all P < 0.001). HRV changes were variable and unreliable. S_po₂ remained consistently above 95%. During a 60 min recovery, HR and CRM returned to baseline on parallel tracks (t^1/2=11 ± 8 and 18 ± 14 min), whereas HRC recovery was slower than either CRM or HR (t^1/2=40 ± 18 min, both P < 0.05).DISCUSSION: Exercise evoked qualitatively similar changes in CRM and HRC. CRM recovered incrementally faster than HRC, suggesting that vasodilation, muscle pump, and respiration compensate faster than cardiac autonomic control in young, healthy volunteers. Both HRC and CRM appear to provide reliable, objective, and noninvasive metrics of human performance in upright exercising individuals.Mulder MB, Eidelson SA, Buzzelli MD, Gross KR, Batchinsky AI, Convertino VA, Schulman CI, Namias N, Proctor KG. Exercise-induced changes in compensatory reserve and heart rate complexity. Aerosp Med Hum Perform. 2019; 90(12):1009-1015.