Gregory A. Watson

Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome.

BACKGROUND Blood transfusion is known to be an independent risk factor for mortality, multiple organ failure (MOF), acute respiratory distress syndrome (ARDS), and nosocomial infection after injury. Less is known about the independent risks associated with plasma-rich transfusion components including fresh frozen plasma (FFP), platelets (PLTS), and cryoprecipitate (CRYO) after injury. We hypothesized that plasma-rich transfusion components would be independently associated with a lower risk of mortality but result in a greater risk of morbid complications. METHODS Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in bluntly injured adults with hemorrhagic shock. All patients required blood transfusion for enrollment. Patients with isolated traumatic brain injury and those not surviving beyond 48 hours were excluded. Cox proportional hazard regression models were used to estimate the outcome risks (per unit) associated with plasma-rich transfusion requirements during the initial 24 hours after injury after controlling for important confounders. RESULTS For the entire study population (n = 1,175), 65%, 41%, and 28% of patients received FFP, PLTS and CRYO, respectively. There was no association with plasma-rich transfusion components and mortality or nosocomial infection. For every unit given, FFP was independently associated with a 2.1% and 2.5% increased risk of MOF and ARDS, respectively. CRYO was associated with a 4.4% decreased risk of MOF (per unit), and PLTS were not associated with any of the outcomes examined. When early deaths (within 48 hours) were included in the model, FFP was associated with a 2.9% decreased risk of mortality per unit transfused. CONCLUSIONS In patients who survive their initial injury, FFP was independently associated with a greater risk of developing MOF and ARDS, whereas CRYO was associated with a lower risk of MOF. Further investigation into the mechanisms by which these plasma-rich component transfusions are associated with these effects are required.

Interferon regulatory factor-1-induced apoptosis mediated by a ligand-independent fas-associated death domain pathway in breast cancer cells

Interferon (IFN) regulatory factor-1 (IRF-1) is a transcription factor that has apoptotic anti-tumor activity. In breast cancer cell types, IRF-1 is implicated in mediating apoptosis by both novel and established anti-tumor agents, including the anti-estrogens tamoxifen and faslodex. Here we demonstrate that in MDA468 breast cancer cells, apoptosis by IFN-γ is mediated by IRF-1 and IFN-γ, and IRF-1-induced apoptosis is caspase-mediated. IRF-1 induction results in cleavage of caspase-8, -3 and -7, and application of caspase inhibitors attenuate activated cleavage products. IRF-1-induced apoptosis involves caspase-8 since apoptosis is significantly decreased by the caspase-8-specific inhibitor IETD, c-FLIP expression and in caspase-8-deficient cancer cells. Furthermore, we demonstrate that IRF-1-induced apoptosis requires fas-associated death domain (FADD) since dominant-negative FADD expressing cells resist IRF-1-induced apoptosis and activated downstream products. Immunofluorescent studies demonstrate perinuclear colocalization of FADD and caspase-8. Despite the known role of FADD in mediating death-ligand induced apoptosis, neutralizing antibodies against classical death receptors do not inhibit IRF-1 induced apoptosis, and no secreted ligand appears to be involved since MDA468 coincubated with IRF-1 transfected cells do not apoptose. Therefore, we demonstrate that IRF-1 induces a ligand-independent FADD/caspase-8-mediated apoptosis in breast cancer cells.

Nonoperative management of blunt splenic injury: what is new?

Abstract The majority of splenic injuries are currently managed nonoperatively. The primary indication for operative management of blunt splenic injury is hemodynamic instability. Findings which correlate with failure of nonoperative management include grade IV or V splenic injury, high Injury Severity Scores, or active extravasation. The role of angiograph/embolization is becoming better defined, appropriate in the patient with pseudoaneurysm or active extravasation or the stable patient with grade IV or V splenic injury.

Incidental radiographic findings after injury: dedicated attention results in improved capture, documentation, and management.

BACKGROUND With liberal use of computed tomography in the diagnostic management of trauma patients, incidental findings are common and represent a major patient-care and medical-legal concern. Consequently, we began an initiative to capture, notify, and documentadequately incidental finding events with a dedicated incidental finding coordinator. We hypothesized a dedicated incidental finding coordinator would increase incidental finding capture and promote notification, follow-up, and documentation of incidental finding events. METHODS A quality-improvement project to record and follow-up incidental findings postinjury was initiated at our level I trauma center (April 2007-March 2008, prededicated incidental finding). Because of concerns for inadequate documentation of identified incidental finding events, we implemented a dedicated incidental finding coordinator (April 2008-March 2009, postdedicated incidental finding). The dedicated incidental finding coordinator documented incidental findings daily from trauma admission radiology final reads. Incidental findings were divided into 3 groups; category 1: attention prior to discharge; category 2: follow-up with primary doctor within 2 weeks; category 3: no specific follow-up. For category 1 incidental findings, in-hospital consultation of the appropriate service was verified. On discharge, patient notification, follow-up, and documentation of events were confirmed. Certified mail or telephone contact was used to notify either the patient or the primary doctor in those who lacked appropriate notification or documentation. RESULTS Admission rates and incidental finding categories were similar across the 2 time periods. Implementation of a dedicated incidental finding coordinator resulted in more than a 165% increase in incidental finding capture (n = 802 vs n = 302; P < .001). Patient notification was attempted, and appropriate documentation of events was confirmed in 99.8% of patients. Patient notification was verified, and follow-up was initiated in 95.8% of cases. CONCLUSION The implementation of a dedicated incidental finding coordinator resulted in more than a 2.5-fold higher capture of incidental findings. Dedicated attention to incidental findings resulted in a near complete initiation of patient notification, follow-up, and hospital record documentation of incidental finding events. Inadequate patient notification and follow-up would delay appropriate care and potentially would result in morbidity or even mortality. A dedicated incidental finding coordinator represents a potential solution to this patient-care and medical-legal dilemma.

Computed tomography abbreviated assessment of sarcopenia following trauma: The CAAST measurement predicts 6-month mortality in older adult trauma patients.

BACKGROUND Older adult trauma patients are at increased risk of poor outcome, both immediately after injury and beyond hospital discharge. Identifying patients early in the hospital stay who are at increased risk of death after discharge can be challenging. METHODS Retrospective analysis was performed using our trauma registry linked with the social security death index from 2010 to 2014. Age was categorized as 18 to 64 and 65 years or older. We calculated mortality rates by age category then selected elderly patients with mechanism of injury being a fall for further analysis. Computed Tomography Abbreviated Assessment of Sarcopenia for Trauma (CAAST) was obtained by measuring psoas muscle cross-sectional area adjusted for height and weight. Kaplan-Meier survival analysis was performed, and proportional hazards regression modeling was used to determine independent risk factors for in-hospital and out-of-hospital mortality. RESULTS A total of 23,622 patients were analyzed (16,748, aged 18–64 years; and 6,874, aged 65 or older). In-hospital mortality was 1.96% for ages 18 to 64 and 7.19% for age 65 or older (p < 0.001); postdischarge 6-month mortality was 1.1% for ages 18 to 64 and 12.86% for age 65 or older (p < 0.001). Predictors of in-hospital and postdischarge mortality for ages 18 to 64 and in-hospital mortality for ages 65 or older group included injury characteristics such as ISS, admission vitals, and head injury. Predictors of postdischarge mortality for age 65or older included skilled nursing before admission, disposition, and mechanism of injury being a fall. A total of 57.5% (n = 256) of older patients who sustained a fall met criteria for sarcopenia. Sarcopenia was the strongest predictor of out-of-hospital mortality in this cohort with a hazard ratio of 4.77 (95% confidence interval, 2.71–8.40; p < 0.001). CONCLUSION Out of hospital does not assure out of danger for the elderly. Sarcopenia is a strong predictor of 6-month postdischarge mortality for older adults. The CAAST measurement is an efficient and inexpensive measure that can allow clinicians to target older trauma patients at risk of poor outcome for early intervention and/or palliative care services. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Redefining acute care surgery: Surgical rescue.

A care surgery (ACS) was initially proposed by the American Association for the Surgery of Trauma as a specialty composed of trauma, surgical critical care, and emergency surgery. In addition, we and others have always considered elective general surgery as a vital component of our ACS service. The promulgation of ACS has filled the public need for surgeons who provide care to the critically ill and injured patients in our hospitals. During the past several years, it has become apparent to us that a crucial service that we provide to both our hospital and the region is that of surgical rescue. Surgical rescue is essentially pulling the patient from the fire after they have developed a complication from surgical or medical care. In reviewing national hospital discharge data, ‘‘complication of medical or surgical care’’ is a more frequent diagnosis than bowel obstruction, cholecystitis, and appendicitis combined. Thus, this is a common clinical diagnosis in a group of patients who are often desperately ill after a medical or surgical complication. In reviewing data from our institution, 10% of our general surgery (nontrauma) admissions/consults are for surgical rescue from a major complication. On average, we see a patient per day requiring surgical rescueVmore than 80% require an operation, and more than half require multiple procedures to be rescued from their complication. Importantly, 50% of these patients are from other services (the majority surgical) within our hospital, 25% from the region, and 25% on our own service. Provision of this immediate care to extricate a patient from a major complication is mandatory for the successful care of the complex patients in our regions and on the thoracic, vascular, cardiac, medical, and other services within our hospitals. Recent reports have shown that the incidence of complications at high-performing versus low-performing hospitals is not as different as one would intuitively suspect. The difference is in the ability to save the patient who has developed a major complication. A high-performing hospital rescues the patient from the complication; the low-performing hospital does not. Our hospital administrators will certainly be familiar with the term failure to rescue but may not understand the vital role of the ACS surgeon in providing surgical rescue. As ACS matures and evolves, it is clear that an essential component of ACS is the immediate care that we provide in surgical rescue of the patient who has developed a complication of his or her medical or surgical care. Moving forward, the essential components of ACS should be redefined as trauma, surgical critical care, emergency and elective surgery, and surgical rescue.

AMERICAN COLLEGE OF SURGEONS TRAUMA CENTER VERIFICATION VERSUS STATE DESIGNATION: ARE LEVEL II CENTERS SLIPPING THROUGH THE CRACKS?

BACKGROUND Single-center experience has shown that American College of Surgeons (ACS) trauma verification can improve outcomes. The current objective was to compare mortality between ACS-verified and state-designated centers in a national sample. METHODS Subjects 16 years or older from ACS-verified or state-designated Level I and II centers were identified in the National Trauma Databank 2007 to 2008. A predictive mortality model was constructed using Trauma Quality Improvement Project methodology. Imputation was used for missing data. Probability of mortality in the model determined expected deaths. Observed-to-expected (O/E) mortality ratios with 90% confidence interval (CI) and outliers (90% CI more than or less than 1.0) were compared across ACS and state Level I and II centers. The mortality model was repeated with ACS versus state included. RESULTS There were 900,274 subjects. The model had an area under the curve of 0.92 to predict death. Level I ACS centers had a lower median O/E ratio compared with state centers (0.95 [interquartile range, 0.82–1.05] vs. 1.02 [interquartile range, 0.87–1.15]; p < 0.01), with no difference in Level II centers. Level II state centers had more high O/E outliers. ACS verification was an independent predictor of survival in Level II centers (odds ratio, 1.26; 95% CI, 1.20–1.32; p < 0.01) but not in Level I centers (p = 0.84). CONCLUSION Level II centers have a disproportionate number of high mortality outliers, and ACS verification is a predictor of survival. Level I ACS centers have lower O/E ratios overall, but no difference in outliers. ACS verification seems beneficial. These data suggest that Level II centers benefit most, and promoting Level II ACS verification may be an opportunity for improved outcomes. LEVEL OF EVIDENCE Prognostic study, level III.

Differential Diagnosis in a 3-Station Acute Abdominal Pain Objective Structured Clinical Examination (OSCE): A Needs Assessment in Third-Year Medical Student Performance and Summative Evaluation in the Surgical Clerkship

BACKGROUND There is poor interrater reliability in the assessment of a medical students ability to generate a differential diagnosis list using Likert-based scales in the surgical clerkship. This important clinical skill is tested on the United States Medical Licensing Examination Step 2 Clinical Skills Examination. OBJECTIVE We hypothesize that third-year medical students in the surgical clerkship will be able to accurately diagnose adult patients with acute abdominal pain after performing a focused history and physical examination in a 3-station Objective Structured Clinical Examination (OSCE). Second, we want to test our hypothesis that service assessments of a students ability to analyze data will not correspond with OSCE performance. METHODS In this retrospective study, third-year medical student differential diagnosis lists from a 3-station OSCE and medical student clerkship assessments were collected from the 2009-2010 academic year. Differential diagnosis lists were scored for accuracy. Differences between groups were compared with nonparametric statistics, using an α = 0.05. RESULTS Seventy-eight third-year medical students (56.4% female) were evaluated. For 2 stations, more than half of the medical students had the correct diagnosis on the differential diagnosis list (p < 0.0001). For 1 station, less than half of the medical students had the correct diagnosis on the differential diagnosis list (p = 0.0001). There were no differences in the service evaluation scores and the number of correct differential diagnosis lists for the students (p = 0.91). CONCLUSIONS Third-year medical students are generally accurate with the ability to diagnosis adult patients with acute abdominal pain after performing a history and physical examination. Additionally, surgical service faculty and resident assessments of a students ability to analyze data do not correspond with OSCE performance. We recommend some changes that might lead to improved grading for third-year medical students in the surgical clerkship.

Surgical rescue: The next pillar of acute care surgery

BACKGROUND The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of “surgical rescue” in the practice of ACS. METHODS A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index. RESULTS Of 2,410 ACS patients, 320 (13%) required “surgical rescue”: most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients (“local”), whereas 38% were referred from another surgical service (“institutional”) and 26% referred from another institution (“regional”). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between “local” and “institutional” patients, but hospital length of stay and discharge to home were significantly worse in “institutional” referrals. CONCLUSION We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the “surgical rescue” of surgical and procedural complications. LEVEL OF EVIDENCE Epidemiological study, level III; therapeutic/care management study, level IV.

Early lower extremity fracture fixation and the risk of early pulmonary embolus: filter before fixation?

BACKGROUND Venous thromboembolism is a major cause of morbidity and mortality after injury. Prophylactic anticoagulation is often delayed as a result of injuries or required procedures. Those patients at highest risk in this early vulnerable window postinjury are not well characterized. We sought to determine those patients at highest risk for an early pulmonary embolism (PE) after injury. METHODS A retrospective analysis using data derived from a large state wide trauma registry (1997-2007) was performed. Patients with a documented PE and time of occurrence were selected (n = 712). Patients with fat emboli and lower extremity vascular injuries were excluded. Patients with a PE within the first 72 hours of admission (EARLY, n = 122) were compared with those with DELAYED presentation. Kaplan-Meier survival analysis was used to characterize the timing of death between the two groups. Backward stepwise logistic regression was used to determine independent risk factors for EARLY PE relative to those with DELAYED PE. RESULTS EARLY and DELAYED groups were similar in age, gender, Glasgow Coma Scale, emergency department systolic blood pressure, and injury mechanism. The EARLY PE group had a lower Injury Severity Score but injuries more commonly included femur fracture. Kaplan-Meier analysis revealed that EARLY PE patients have a significantly higher risk of early mortality relative to DELAYED PE patients (p = 0.012). Regression analysis revealed that the only independent risk factor for EARLY PE was lower extremity/pelvic orthopedic fixation (<48 hours from injury). The risk of EARLY PE was more than threefold higher (odds ratios, 3.85; 95% CI, 1.9-7.6; p < 0.001) for those who underwent early lower extremity orthopedic fixation versus those who did not. CONCLUSION Early lower extremity/pelvis orthopedic fixation is the single independent predictor of EARLY PE in this patient cohort. Venous thromboembolism/PE prevention strategies should be made a priority in this group of patients, including early preoperative institution of anticoagulation prophylaxis. These results suggest that those with contraindications to early anticoagulation may benefit from insertion of retrievable inferior vena cava filters preoperatively.