Andrew Tang

Superiority of frailty over age in predicting outcomes among geriatric trauma patients: A prospective analysis

IMPORTANCE The Frailty Index (FI) is a known predictor of adverse outcomes in geriatric patients. The usefulness of the FI as an outcome measure in geriatric trauma patients is unknown. OBJECTIVE To assess the usefulness of the FI as an effective assessment tool in predicting adverse outcomes in geriatric trauma patients. DESIGN, SETTING, AND PARTICIPANTS A 2-year (June 2011 to February 2013) prospective cohort study at a level I trauma center at the University of Arizona. We prospectively measured frailty in all geriatric trauma patients. Geriatric patients were defined as those 65 years or older. The FI was calculated using 50 preadmission frailty variables. Frailty in patients was defined by an FI of 0.25 or higher. MAIN OUTCOMES AND MEASURES The primary outcome measure was in-hospital complications. The secondary outcome measure was adverse discharge disposition. In-hospital complications were defined as cardiac, pulmonary, infectious, hematologic, renal, and reoperation. Adverse discharge disposition was defined as discharge to a skilled nursing facility or in-hospital mortality. Multivariate logistic regression was used to assess the relationship between the FI and outcomes. RESULTS In total, 250 patients were enrolled, with a mean (SD) age of 77.9 (8.1) years, median Injury Severity Score of 15 (range, 9-18), median Glasgow Coma Scale score of 15 (range, 12-15), and mean (SD) FI of 0.21 (0.10). Forty-four percent (n = 110) of patients had frailty. Patients with frailty were more likely to have in-hospital complications (odds ratio, 2.5; 95% CI, 1.5-6.0; P = .001) and adverse discharge disposition (odds ratio, 1.6; 95% CI, 1.1-2.4; P = .001). The mortality rate was 2.0% (n = 5), and all patients who died had frailty. CONCLUSIONS AND RELEVANCE The FI is an independent predictor of in-hospital complications and adverse discharge disposition in geriatric trauma patients. This index should be used as a clinical tool for risk stratification in this patient group.

Vagal-sparing esophagectomy: The ideal operation for intramucosal adenocarcinoma and Barrett with high-grade dysplasia

Objective:Our aim was to compare outcome of vagal-sparing esophagectomy with transhiatal and en bloc esophagectomy in patients with intramucosal adenocarcinoma or high-grade dysplasia. Summary Background Data:Intramucosal adenocarcinoma and high grade dysplasia have a low likelihood of lymphatic or systemic metastases and esophagectomy is curative in most patients. However, traditional esophagectomy is associated with significant morbidity and altered gastrointestinal function. A vagal-sparing esophagectomy offers the advantages of complete disease removal with the potential for reduced morbidity and a better functional outcome. Method:Retrospective review of outcome in patients with intramucosal adenocarcinoma or high grade dysplasia that had a vagal-sparing (n = 49), transhiatal (n = 39) or en bloc (n = 21) esophagectomy. Results:The length of hospital stay and the incidence of major complications was significantly reduced with a vagal-sparing esophagectomy compared with a transhiatal or en bloc resection. Further, postvagotomy dumping and diarrhea symptoms were significantly less common, and weight was better maintained postoperatively with a vagal-sparing esophagectomy. Recurrent cancer has developed in only 1 patient. Conclusion:Survival with intramucosal adenocarcinoma or Barretts with high-grade dysplasia is independent of the type of resection. A vagal-sparing esophagectomy is associated with significantly less perioperative morbidity and a shorter hospital stay than a transhiatal or en bloc esophagectomy. Further, late morbidity including weight loss, dumping, and diarrhea are significantly less likely after a vagal-sparing approach. Consequently a vagal-sparing esophagectomy is the preferred procedure for patients with intramucosal adenocarcinoma or high grade dysplasia.

A New Technique for Measurement of Pharyngeal pH: Normal Values and Discriminating pH Threshold

IntroductionIdentifying gastroesophageal reflux disease as the cause of respiratory and laryngeal complaints is difficult and depends largely on the measurements of increased acid exposure in the upper esophagus or ideally the pharynx. The current method of measuring pharyngeal pH environment is inaccurate and problematic due to artifacts. A newly designed pharyngeal pH probe to avoid these artifacts has been introduced. The aim of this study was to use this probe to measure the pharyngeal pH environment in normal subjects and establish pH thresholds to identify abnormality.MethodsAsymptomatic volunteers were studied to define the normal pharyngeal pH environment. All subjects underwent esophagram, esophageal manometry, upper and lower esophageal pH monitoring with a dual-channel pH catheter and pharyngeal pH monitoring with the new probe. Analyses were performed at 0.5 pH intervals between pH 4 and 6.5 to identify the best discriminating pH threshold and calculate a composite pH score to identify an abnormal pH environment.ResultsThe study population consisted of 55 normal subjects. The pattern of pharyngeal pH environment was significantly different in the upright and supine periods and required different thresholds. The calculated discriminatory pH threshold was 5.5 for upright and 5.0 for supine periods. The 95th percentile values for the composite score were 9.4 for upright and 6.8 for supine.ConclusionA new pharyngeal pH probe which detects aerosolized and liquid acid overcomes the artifacts that occur in measuring pharyngeal pH with existing catheters. Discriminating pH thresholds were selected and normal values defined to identify patients with an abnormal pharyngeal pH environment.

Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer?

BACKGROUND The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has never been applied as a prognostic measure after trauma. The aim of our study was to identify hospital admission factors predicting discharge disposition in geriatric trauma patients. METHODS We performed a 1-year prospective study at our Level 1 trauma center. All trauma patients 65 years or older were enrolled. FI was calculated using 50 preadmission variables. Patient’s discharge disposition was dichotomized as favorable outcome (discharge home, rehabilitation) or unfavorable outcomes (discharge to skilled nursing facility, death). Multivariate logistic regression was performed to identify factors that predict unfavorable outcome. RESULTS A total of 100 patients were enrolled, with a mean (SD) age of 76.51 (8.5) years, 59% being males, median Injury Severity Score (ISS) of 14 (range, 9–18), median head Abbreviated Injury Scale (h-AIS) score of 2 (2–3), and median Glasgow Coma Scale (GCS) score of 13 (12–15). Of the patients, 69% had favorable outcome, and 31% had unfavorable outcome. On univariate analysis, FI was found to be a significant predictor for unfavorable outcome (odds ratio, 1.8; 95% confidence interval, 1.2–2.3). After adjusting for age, ISS, and GCS score in a multivariate regression model, FI remained a strong predictor for unfavorable discharge disposition (odds ratio, 1.3; 95% confidence interval, 1.1–1.8). CONCLUSION The concept of frailty can be implemented in geriatric trauma patients with similar results as those of nontrauma and nonsurgical patients. FI is a significant predictor of unfavorable discharge disposition and should be an integral part of the assessment tools to determine discharge disposition for geriatric trauma patients. LEVEL OF EVIDENCE Prognostic study, level II.

Prothrombin complex concentrate: an effective therapy in reversing the coagulopathy of traumatic brain injury.

BACKGROUND Coagulopathy in patients with traumatic brain injury (TBI) is a well-studied concept. Prothrombin complex concentrate (PCC) has been shown to be an effective treatment modality for correction of TBI coagulopathy. However, its use and effectiveness compared with recombinant factor VII (rFVIIa) in TBI has not been established. The purpose of this study was to compare PCC and rFVIIa for the correction of TBI coagulopathy. METHODS All patients with a TBI and an induced or acquired coagulopathy whom received rFVIIa or PCC at our Level I trauma center during a 4-year period were reviewed. Data collected included demographics, changes in international normalized ratio and blood products transfusion, craniotomy rates, and time to neurosurgical intervention, thromboembolic complications, and mortality differences. RESULTS The study was composed of 85 TBI patients, of whom 64 patients received PCC while 21 patients received rFVIIa. PCC group were more likely to be on coumadin (44% vs. 14%, p = 0.01). There was a significant decline in packed red blood cell transfusion and fresh frozen plasma after PCC administration (p < 0.01). There was no statistically significant difference in the craniotomy rate (28% vs. 10 %, p = 0.1) or the mean time to intervention between the two groups (201 [33] vs. 230 [10], p = 0.9). Mortality rates were lower in the PCC group compared with rFVIIa (67% vs. 47%, p = 0.02). Subsequent thromboembolic event was seen in one patient on rFVIIa. Mean cost of treatment per patient on PCC was

The changing epidemiology of spinal trauma: A 13-year review from a Level I trauma centre

1,007 compared with

Improving Survival Rates after Civilian Gunshot Wounds to the Brain

5,757 for rFVIIa (p < 0.01). CONCLUSION PCC is safe and effective for treating coagulopathy in TBI patients, while reducing costs and resource use. PCC should be considered as an effective therapy to treat both acquired and induced coagulopathy in TBI with or without prehospital coumadin use. LEVEL OF EVIDENCE Therapeutic study, level IV.

Shock index predicts mortality in geriatric trauma patients: an analysis of the National Trauma Data Bank

INTRODUCTION Spinal injuries secondary to trauma are a major cause of patient morbidity and a source of significant health care expenditure. Increases in traffic safety standards and improved health care resources may have changed the characteristics and incidence of spinal injury. The purpose of this study was to review a single metropolitan Level I trauma centres experience to assess the changing characteristics and incidence of traumatic spinal injuries and spinal cord injuries (SCI) over a 13-year period. PATIENTS AND METHODS A retrospective review of patients admitted to a Level I trauma centre between 1996 and 2008 was performed. Patients with spinal fractures and SCI were identified. Demographics, mechanism of injury, level of spinal injury and Injury Severity Score (ISS) were extracted. The outcomes assessed were the incidence rate of SCI and in-hospital mortality. RESULTS Over the 13-year period, 5.8% of all trauma patients suffered spinal fractures, with 21.7% of patients with spinal injuries having SCI. Motor vehicle accidents (MVAs) were responsible for the majority of spinal injuries (32.6%). The mortality rate due to spinal injury decreased significantly over the study period despite a constant mean ISS. The incidence rate of SCI also decreased over the years, which was paralleled by a significant reduction in MVA associated SCI (from 23.5% in 1996 to 14.3% in 2001 to 6.7% in 2008). With increasing age there was an increase in spinal injuries; frequency of blunt SCI; and injuries at multiple spinal levels. CONCLUSION This study demonstrated a reduction in mortality attributable to spinal injury. There has been a marked reduction in SCI due to MVAs, which may be related to improvements in motor vehicle safety and traffic regulations. The elderly population was more likely to suffer SCI, especially by blunt injury, and at multiple levels. Underlying reasons may be anatomical, physiological or mechanism related.

The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons.

BACKGROUND Gunshot wounds to the brain are the most lethal of all firearm injuries, with reported survival rates of 10% to 15%. The aim of this study was to determine outcomes in patients with gunshot wounds to the brain, presenting to our institution over time. We hypothesized that aggressive management can increase survival and the rate of organ donation in patients with gunshot wounds to the brain. STUDY DESIGN We analyzed all patients with gunshot wounds to the brain presenting to our level 1 trauma center over a 5-year period. Aggressive management was defined as resuscitation with blood products, hyperosmolar therapy, and/or prothrombin complex concentrate (PCC). The primary outcome was survival and the secondary outcome was organ donation. RESULTS There were 132 patients with gunshot wounds to the brain, and the survival rates increased incrementally every year, from 10% in 2008 to 46% in 2011, with the adoption of aggressive management. Among survivors, 40% (16 of 40) of the patients had bi-hemispheric injuries. Aggressive management with blood products (p = 0.02) and hyperosmolar therapy (p = 0.01) was independently associated with survival. Of the survivors, 20% had a Glasgow Coma Scale score ≥ 13 at hospital discharge. In patients who died (n = 92), 56% patients were eligible for organ donation, and they donated 60 organs. CONCLUSIONS Aggressive management is associated with significant improvement in survival and organ procurement in patients with gunshot wounds to the brain. The bias of resource use can no longer be used to preclude trauma surgeons from abandoning aggressive attempts to save patients with gunshot wound to the brain.

The conjoint effect of reduced crystalloid administration and decreased damage-control laparotomy use in the development of abdominal compartment syndrome

BACKGROUND Heart rate and systolic blood pressure are unreliable in geriatric trauma patients. Shock index (SI) (heart rate/systolic blood pressure) is a simple marker of worse outcomes after injury. The aim of this study was to assess the utility of SI in predicting outcomes. We hypothesized that SI predicts mortality in geriatric trauma patients. METHODS We performed a 4-year (2007–2010) retrospective analysis using the National Trauma Data Bank. Patients 65 years or older were included. Transferred patients, patients dead on arrival, missing vitals on presentation, and patients with burns and traumatic brain injury were excluded. A cutoff value of SI greater than or equal to 1 (sensitivity, 81%; specificity, 79%) was used to define hemodynamic instability. The primary outcome measure was mortality. Secondary outcome measures were need for blood transfusion, need for exploratory laparotomy, and development of in-hospital complications. Multiple logistic regressions were performed. RESULTS A total of 485,595 geriatric patients were reviewed, of whom 217,190 were included. The mean (SD) age was 77.7 (7.1) years, 60% were males, median Glasgow Coma Scale (GCS) score was 14 (range, 3–15), median Injury Severity Score (ISS) was 9 (range, 4–18), and mean (SD) SI was 0.58 (0.18). Three percent (n = 6,585) had an SI greater than or equal to 1. Patients with SI greater than or equal to 1 were more likely to require blood product requirement (p = 0.001), require an exploratory laparotomy (p = 0.01), and have in-hospital complications (p = 0.02). The overall mortality rate was 4.1% (n = 8,952). SI greater than or equal to 1 was the strongest predictor for mortality (odds ratio, 3.1; 95% confidence interval, 2.6–3.3; p = 0.001) in geriatric trauma patients. Systolic blood pressure (p = 0.09) and heart rate (p = 0.2) were not predictive of mortality. CONCLUSION SI is an accurate and specific predictor of morbidity and mortality in geriatric trauma patients. SI is superior to heart rate and systolic blood pressure for predicting mortality in geriatric trauma patients. Geriatric trauma patients with SI greater than or equal to 1 should be transferred to a Level 1 trauma center. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.