Charles de Mestral

Flail chest injuries: A review of outcomes and treatment practices from the National Trauma Data Bank

BACKGROUND Flail chest injuries are associated with severe pulmonary restriction, a requirement for intubation and mechanical ventilation, and high rates of morbidity and mortality. Our goals were to investigate the prevalence, current treatment practices, and outcomes of flail chest injuries in polytrauma patients. METHODS The National Trauma Data Bank was used for a retrospective analysis of the injury patterns, management, and clinical outcomes associated with flail chest injuries. Patients with a flail chest injury admitted from 2007 to 2009 were included in the analysis. Outcomes included the number of days on mechanical ventilation, days in the intensive care unit (ICU), days in the hospital, and rates of pneumonia, sepsis, tracheostomy, chest tube placement, and death. RESULTS Flail chest injury was identified in 3,467 patients; the mean age was 52.5 years, and 77% of the patients were male. Significant head injury was present in 15%, while 54% had lung contusions. Treatment practices included epidural catheters in 8% and surgical fixation of the chest wall in 0.7% of the patients. Mechanical ventilation was required in 59%, for a mean of 12.1 days. ICU admission was required in 82%, for a mean of 11.7 days. Chest tubes were used in 44%, and 21% required a tracheostomy. Complications included pneumonia in 21%, adult respiratory distress syndrome in 14%, sepsis in 7%, and death in 16%. Patients with concurrent severe head injury had higher rates of ventilatory support and ICU stay and had worse outcomes in every category compared with those without a head injury. CONCLUSION Patients who have sustained a flail chest have significant morbidity and mortality. More than 99% of these patients were treated nonoperatively, and only a small proportion (8%) received aggressive pain management with epidural catheters. Given the high rates of morbidity and mortality in patients with a flail chest injury, alternate methods of treatment including more consistent use of epidural catheters for pain or surgical fixation need to be investigated with large randomized controlled trials. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level IV.

Intracranial pressure monitoring in severe traumatic brain injury: results from the American College of Surgeons Trauma Quality Improvement Program.

Although existing guidelines support the utilization of intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI), the evidence suggesting benefit is limited. To evaluate the impact on outcome, we determined the relationship between ICP monitoring and mortality in centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP). Data on 10,628 adults with severe TBI were derived from 155 TQIP centers over 2009-2011. Random-intercept multilevel modeling was used to evaluate the association between ICP monitoring and mortality after adjusting for important confounders. We evaluated this relationship at the patient level and at the institutional level. Overall mortality (n=3769) was 35%. Only 1874 (17.6%) patients underwent ICP monitoring, with a mortality of 32%. The adjusted odds ratio (OR) for mortality was 0.44 [95% confidence interval (CI), 0.31-0.63], when comparing patients with ICP monitoring to those without. It is plausible that patients receiving ICP monitoring were selected because of an anticipated favorable outcome. To overcome this limitation, we stratified hospitals into quartiles based on ICP monitoring utilization. Hospitals with higher rates of ICP monitoring use were associated with lower mortality: The adjusted OR of death was 0.52 (95% CI, 0.35-0.78) in the quartile of hospitals with highest use, compared to the lowest. ICP monitoring utilization rates explained only 9.9% of variation in mortality across centers. Results were comparable irrespective of the method of case-mix adjustment. In this observational study, ICP monitoring utilization was associated with lower mortality. However, variability in ICP monitoring rates contributed only modestly to variability in institutional mortality rates. Identifying other institutional practices that impact on mortality is an important area for future research.

Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis.

Objective:To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis. Background:Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death. Methods:This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication. Results:From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury [0.28% vs 0.53%, relative risk (RR) = 0.53, 95% confidence interval [CI]: 0.31–0.90], of major bile duct injury or death (1.36% vs 1.88%, RR = 0.72, 95% CI: 0.56–0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR = 0.73, 95% CI: 0.47–1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7–2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR = 1.07, 95% CI: 0.99–1.16) or in conversion among laparoscopic cases (11% vs 10%, RR = 1.02, 95% CI: 0.93–1.13). Conclusions:These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.

The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis.

BACKGROUND By ensuring timely access to trauma center (TC) care, well-organized trauma systems have the potential to significantly reduce injury-related mortality. However, undertriage continues to be a significant problem in many regional trauma systems. Taking a novel, population-based approach, we estimated the potential detrimental impact of undertriage to a non-TC (NTC) within a regional system. METHODS We performed a population-based, retrospective cohort study of TC effectiveness in a region with urban, suburban, and rural areas. Data were derived from administrative databases capturing all emergency department deaths and admissions in the region. Adult motor vehicle collision occupants presenting to any emergency department in the study region were included (2002–2010). Data were limited to patients with severe injury. The exposure of interest was initial triage destination (TC or NTC), regardless of later transfer to TC. Mortality was compared across groups, using an instrumental variable analysis to adjust for confounding. RESULTS Among 6,341 motor vehicle collision occupants, 45% (n = 2,857) were triaged from the scene of injury to a TC. Among patients transported from the scene to a NTC, 57% (n = 2,003) were transferred to a TC within 24 hours of initial evaluation. Compared with patients triaged to a NTC, adjusted mortality was lower among patients triaged directly to a TC, both at 24 hours (odds ratio: 0.58, 95% confidence interval: 0.41–0.84) and at 48 hours (odds ratio: 0.68, 95% confidence interval: 0.48–0.96). A trend toward reduced mortality with TC triage was also observed at 7 and 30 days. CONCLUSIONS Our data are population-based evidence of the early benefits of direct triage to TC. Although many surviving patients are later transferred to a TC, initial triage to a NTC is associated with at least a 30% increase in mortality in the first 48 hours after injury. LEVEL OF EVIDENCE Therapeutic study, level IV.

A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged without cholecystectomy

BACKGROUND Randomized trials and expert opinion support early laparoscopic cholecystectomy for most patients with acute cholecystitis (AC); however, practice patterns remain variable worldwide, and delayed cholecystectomy remains a common practice. We therefore present a population-based analysis of the clinical course of patients with AC discharged without cholecystectomy. METHODS Using administrative databases capturing all emergency department (ED) visits and hospital admissions within a geographic region encompassing 13 million persons, we identified adults with a first emergency admission for uncomplicated AC during the period of 2004 to 2011. In those discharged without cholecystectomy, the probability of a subsequent gallstone-related event (gallstone-related ED visit or hospital admission) was evaluated using Kaplan-Meier methods. The association of patient characteristics with time to first gallstone-related event after discharge was explored through multivariable time to event analysis. RESULTS Of 25,397 patients with AC, 10,304 (41%) did not undergo cholecystectomy on first admission. The probability of a gallstone-related event by 6 weeks, 12 weeks, and 1 year after discharge was 14%, 19%, and 29% respectively. Of these events, 30% were for biliary tract obstruction or pancreatitis. When controlling for sex, income, and comorbidity level, the risk of a gallstone-related event was highest for patients 18 years to 34 years old. CONCLUSION For patients who do not undergo cholecystectomy on first admission for AC, the probability of a gallstone-related ED visit or hospital admission within 12 weeks of discharge is 19%. The increased risk in younger patients reinforces the value of early cholecystectomy in the nonelderly. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

The Impact of Distance on Triage to Trauma Center Care in an Urban Trauma System

Abstract Background. Urban trauma systems are characterized by high population density, availability of trauma centers, and acceptable road transport times (within 30 minutes). In such systems, patients meeting field trauma triage (FTT) criteria should be transported directly to a trauma center, bypassing closer non–trauma centers. Objective. We evaluated emergency medical services (EMS) triage practices to identify opportunities for improving care delivery. Objective. Specifically, we evaluated the effect of the additional distance to a trauma center, compared with a closer non–trauma center, on the noncompliance with trauma destination criteria by EMS personnel in an urban environment. Methods. This was a retrospective cohort study of adults having at least one physiologic derangement and meeting Toronto EMS field trauma triage criteria from 2005 to 2010. Road travel distances between the site of injury, the closest non–trauma center, and the closest trauma center were estimated using geographic information systems. For patients who were transported to non–trauma centers, we estimated “differential distance”: the additional travel distance required to transport directly to a trauma center. Logistic regression was used to analyze the effect of differential distance on triage decisions, adjusting for other patient characteristics. Results. Inclusion criteria identified 898 patients; 53% were transported directly to a trauma center. Falls, female gender, and age greater than 65 years were associated with transport to non–trauma centers. Differential distances greater than 1 mile were associated with a decreased likelihood of triage to a trauma center. Conclusion. Differential distance between the closest non–trauma center and the closest trauma center was associated with lower compliance with triage protocols, even in an urban setting where trauma centers can be accessed within approximately 30 minutes. Our findings suggest that there are opportunities for reducing the gap between ideal and actual application of field trauma triage guidelines through a process of education and feedback.

Close to home: an analysis of the relationship between location of residence and location of injury.

BACKGROUND Injury surveillance is critical in identifying the need for targeted prevention initiatives. Understanding the geographic distribution of injuries facilitates matching prevention programs with the population most likely to benefit. At the population level, however, the geographic site of injury is rarely known, leading to the use of location of residence as a surrogate. To determine the accuracy of this approach, we evaluated the relationship between the site of injury and of residence over a large geographic area. METHODS Data were derived from a population-based, prehospital registry of persons meeting triage criteria for major trauma. Patients dying at the scene or transported to the hospital were included. Distance between locations of residence and of injury was calculated using geographic information system network analysis. RESULTS Among 3,280 patients (2005–2010), 88% were injured within 10 miles of home (median, 0.2 miles). There were significant differences in distance between residence and location of injury based on mechanism of injury, age, and hospital disposition. The large majority of injuries involving children, the elderly, pedestrians, cyclists, falls, and assaults occurred less than 10 miles from the patient’s residence. Only 77% of motor vehicle collision occurred within 10 miles of the patient’s residence. CONCLUSION Although the majority of patients are injured less than 10 miles from their residence, the probability of injury occurring “close to home” depends on patient and injury characteristics. LEVEL OF EVIDENCE Epidemiologic study, level III.

Population-based analysis of blunt splenic injury management in children: operative rate is an informative quality of care indicator.

BACKGROUND In hemodynamically normal children with blunt splenic injury (BSI), the standard of care is non-operative management. Several studies have reported that non-paediatric and non-trauma centres have higher operative rates in children with BSI compared to paediatric hospitals and trauma centres. We investigate the feasibility of using operative rate for BSI as a quality of care indicator. METHODS We performed a population-based retrospective cohort study of children (≤18 years) with BSI admitted to all acute-care hospitals in Canada from 2001 to 2010. The main outcome was rate of operative management for BSI. Hierarchical multivariable logistic regression models were constructed to evaluate the relationship between operative rate and different hospital types (paediatric or non-paediatric, trauma or non-trauma). These models also allowed for generation of hospital-level observed to expected (O/E) ratios for rate of operative management. RESULTS We identified 3122 children with BSI. The majority (74%) were isolated splenic injuries and the grade of splenic injury was specified in 45% of cases (n=1391, 38% grade I or II; 62% grade III, IV, or V). The overall operative rate was 11% (n=315), of which 9% were total splenectomy and 2% were spleen-preserving operations. After adjusting for age, gender, mechanism of injury, splenic injury grade, ISS, and centre volume, admission to non-paediatric hospitals was associated with a higher probability of operative management (OR 7.6, 95% CI 2.4-24.4), whereas there was no significant difference in operative management between trauma and non-trauma centres (OR 1.6, 95% CI 0.8-3.2). Outlier status based on O/E ratio was determined to identify centres with higher or lower than expected operative rates. CONCLUSIONS The operative rates for children with BSI are significantly higher in non-paediatric hospitals. In these hospitals that do not routinely care for children and have higher than expected operative rates, we have used operative rate for BSI as a quality of care indicator and identified opportunities for quality improvement initiatives. LEVEL OF EVIDENCE III, Retrospective comparative study.

Benchmarking trauma center performance in traumatic brain injury: the limitations of mortality outcomes

BACKGROUND Trauma centers (TCs) generally use mortality to gauge performance. However, differences in mortality outcomes might reflect different approaches or philosophies toward end-of-life care. We postulate that discharge home (DH) as a proxy for functional outcome may be a more useful measure of quality and may have significant implications on the assessment of TC performance and external benchmarking efforts. METHODS Data were derived from the National Trauma Data Bank (2007–2009). We included patients (18 years or older) with isolated, severe blunt head injuries who were admitted to Level I and Level II TCs. Observed-to-expected (O/E) mortality ratios were calculated and used to rank TC performance by mortality and then DH. Concordance between performance measures was calculated using a weighted kappa statistic. RESULTS In total, 19,705 patients in 240 TCs were identified. Crude mortality ranged from 4% to 60%, whereas rates of DH ranged from 3% to 66%. When O/E ratios for mortality were evaluated, five centers were identified as high performers. Of these five centers, only two were also high performers for DH. The concordance of outlier status and correlation across O/E ratios between mortality and DH high performers was 0.16 (poor). CONCLUSION Centers that are characterized as high performers when evaluating mortality are not high performers for functional outcome as evaluated by DH. DH may provide an alternative way of assessing quality of care delivered to patients with traumatic brain injury. LEVEL OF EVIDENCE Care management study, level III.

Lower Limb Amputations in Patients With Diabetes and Peripheral Artery Disease: A Time-Series Analysis of Trends (2005-2016)

have a relatively higher degree of stent recoil than metal does. Hence, we hereby intended to develop novel composite bioresorbable stents (cBRSs) made of poly(pdioxanone) (PPDO) and polycaprolactone with mechanically reinforced compression performance for pediatric patients. Methods: The cBRSs with PPDO monofilaments and PPDO-polycaprolactone composite braiding yarns were fabricated on a 32-bobbin braiding machine using different ratios (7:1 for cBRS type A and 3:1 for cBRS type B) and thermally treated in air thereafter. The properties of different prototypes compressed were evaluated by a parallel compression tester. Stent stress distribution and deformation mechanisms were also analyzed by the finite element method. Results: Partial interlacing yarns were bonded, and the peeling force was as high as 2126.67 6 133.14 mN to restrict their movement greatly compared with the friction resistance (<100 mN) in the control group. The compression force was promoted dramatically in the novel composite prototype stents by 124.06% in cBRS type A and 169.58% in cBRS type B. Besides, the recovery abilities were also improved significantly. Moreover, deformation mechanisms revealed by computational simulations showed that bonded interlacing points among yarn played an important role. Conclusions: This study demonstrated a novel technique for designing bioresorbable polymeric prototype stents with reinforced compression performance using a braiding and annealing procedure. The advantage of this design lies in the bonded strand interlacing points that restricted stent elongation and yarn gliding, which was revealed by computational simulations. In addition, the degradation behavior of novel composite braided stents will be evaluated in the future.