Kaushik Mukherjee

Feasibility of screening for preinjury frailty in hospitalized injured older adults

BACKGROUND Frailty assessment of injured older adults (IOAs) is important for clinical management; however, the feasibility of screening for preinjury frailty has not been established in a Level I trauma center. The aims of our study were to assess enrollment rates of IOAs and their surrogates as well as completion rates of selected brief frailty screening instruments. METHODS We conducted a prospective cohort study on patients, age 65 years and older with a primary injury diagnosis. Patients and/or surrogates were interviewed within 48 hours of admission using the Vulnerable Elders Survey (VES-13), Barthel Index (BI), and the Life Space Assessment (LSA). Data analysis included frequency distributions, &khgr;2 statistics, Mann-Whitney and Kruskal-Wallis tests, and general linear modeling (analysis of variance). RESULTS Of 395 admitted patients, 188 were enrolled with subsequent surrogate screening. Corresponding patient interviews were conducted for 77 patients (41%). Screening time was less than 5 minutes for each instrument, and item completion was 100%. Forty-two enrolled patients (22%) had nurse-reported delirium, and 69 (37%) patients either did not feel like answering questions or were unable to be interviewed secondary to their medical condition. The median score of surrogate responses for the VES-13 was 3.5 (interquartile range, 2–7), with 64% of the sample having a score of 3 or greater, indicating vulnerability or frailty. Median scores for the BI (19.0) and LSA (56.0) indicated high numbers with limitations in activities of daily living and limitations in mobilization. CONCLUSION Screening for preinjury frailty in IOAs is feasible yet highly dependent on the presence of a surrogate respondent. A clinically significant percentage of patients have functional deficits consistent with frailty, dependence in activities of daily living, and limitations in mobilization. Implementation of validated brief screening instruments to identify frailty in clinical settings is warranted for targeting timely, efficient, and effective care interventions. LEVEL OF EVIDENCE Epidemiologic study, level II.

Stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries

BACKGROUND Hyperglycemia in nondiabetic patients outside the intensive care unit is not well defined. We evaluated the relationship of hyperglycemia and surgical site infection (SSI) in stable nondiabetic patients with orthopedic injuries. METHODS We conducted a prospective observational cohort study at a single academic Level 1 trauma center over 9 months (Level II evidence for therapeutic/care management). We included patients 18 years or older with operative orthopedic injuries and excluded patients with diabetes, corticosteroid use, multisystem injuries, or critical illness. Demographics, medical comorbidities (American Society of Anesthesiologists class), body mass index, open fractures, and number of operations were recorded. Fingerstick glucose values were obtained twice daily. Hyperglycemia was defined as a fasting glucose value greater than or equal to 125 mg/dL or a random value greater than or equal to 200 mg/dL on more than one occasion before the diagnosis of SSI. Glycosylated hemoglobin level was obtained from hyperglycemic patients; those with glycosylated hemoglobin level of 6.0 or greater were considered occult diabetic patients and were excluded. SSI was defined by a positive intraoperative culture at reoperation within 30 days of the index case. RESULTS We enrolled 171 patients. Of these 171, 40 (23.4%) were hyperglycemic; 7 of them were excluded for occult diabetes. Of the 164 remaining patients, 33 were hyperglycemic (20.1%), 50 had open fractures (6 Type I, 22 Type II, 22 Type III), and 12 (7.3%) had SSI. Hyperglycemic patients were more likely to develop SSI (7 of 33 [21.2%] vs. 5 of 131 [3.8%], p = 0.003). Open fractures were associated with SSI (7 of 50 [14%] vs. 5 of 114 [4.4%], p = 0.047) but not hyperglycemia (10 of 50 [20.0%] vs. 23 of 114 [20.2%], p = 0.98). There was no significant difference between infected and noninfected patients in terms of age, sex, race, American Society of Anesthesiologists class, obesity (body mass index > 29), tobacco use, or number of operations. CONCLUSION Stress hyperglycemia was associated with SSI in this prospective observational cohort of stable nondiabetic patients with orthopedic injuries. Further prospective randomized studies are necessary to identify optimal treatment of hyperglycemia in the noncritically ill trauma population. LEVEL OF EVIDENCE Therapeutic study, level III.

Preinjury physical frailty and cognitive impairment among geriatric trauma patients determine postinjury functional recovery and survival.

BACKGROUND Injury is an external stressor that often initiates a cycle of decline in many older adults. The influence of physical frailty and cognitive decline on 6-month and 1-year outcomes after injury is unreported. We hypothesized that physical frailty and cognitive impairment would be predictive of 6-month and 1-year postinjury function and overall mortality. METHODS The sample involved patients who are 65 years or older admitted to a Level I trauma center between October 2013 and March 2014 with a primary injury diagnosis. Surrogates of 188 patients were interviewed within 48 hours of hospital admission to determine preinjury cognitive and physical frailty impairments using brief screening instruments. Follow-up was completed on 172 patients at 6 months and 176 patients at 1 year to determine posthospitalization status and outcomes. Data analysis involved frequencies, measures of central tendency, &khgr;2 analyses, linear and logistic regression. RESULTS The mean age of the patients was 77 years. The median Injury Severity Score (ISS) was 10. The mechanism of injury involved falls from standing (n = 101, 54%). Preinjury vulnerabilities included cognitive impairment (AD8 Dementia Screen [AD8] score ≥ 2, n = 93, 50%) and physical frailty (Vulnerable Elders Survey [VES-13] score ≥ 4, n = 94, 50%). Overall, median physical frailty scores did not return to baseline in the majority of survivors at 1 year. Multivariate regression analysis revealed that preinjury cognitive impairment (6 months, AD8, &bgr; = −0.20, p = 0.002) and preinjury physical frailty (6 months, Barthel Index, &bgr; = 0.60, p < 0.001; 1 year, Barthel Index, &bgr; = 0.52, p < 0.001) are independently associated with physical function (frailty). Multivariate logistic regression analysis revealed that age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04–1.14), injury severity (OR, 1.07; 95% CI, 1.02–1.12), and preinjury physical frailty (OR, 1.28; 95% CI, 1.14–1.47) are independently associated with overall mortality at 1 year. CONCLUSION Preinjury physical frailty is the predominant predictor of postinjury functional status and mortality in geriatric trauma patients. Identification of frailty and appropriate follow-up are crucial for decision making by providers, patients, and family caregivers. LEVEL OF EVIDENCE Prognostic study, level II.

All trauma surgeons are not created equal: asymmetric distribution of malpractice claims risk.

BACKGROUND Trauma surgery is perceived to have high malpractice risk. Unsolicited patient complaints (UPCs) can predict increased malpractice risk. An ex ante analysis of UPCs was performed to determine the risk profile for trauma surgeons compared with nontrauma surgeons. METHODS UPCs from 14 health systems over 4 years were retrospectively studied. Surgeons were divided into nontrauma surgeons (NTS) and trauma surgeons (TS). Inclusion criteria for TS were practice at a Level I or geographically isolated Level II adult trauma center and either surgical critical care certification or American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, or Western Trauma Association membership. Standardized risk scores were generated using a weighted sum algorithm from UPC data. Mann-Whitney U test, Kolvogorov-Smirnov two-sample test for distribution, χ for linear trend, and relative risk analysis were performed. RESULTS A total of 16,518 UPCs were filed against 4,244 surgeons, including 55 TS. 18% of TS and 57% of NTS had 0 UPCs. Mean risk score was higher for TS (29.2 ± 29.0 vs. 10.2 ± 19.5, p < 0.001), and more TS (20.0% vs. 3.15%) were at moderate (score 50-69) or at high risk (score >70) (7.27% vs. 2.57%; p < 0.001), reflecting a shifted risk distribution (p < 0.001) compared with NTS. TS have a relative risk of 6.17 (95% CI: 3.36-11.33) for score >50. CONCLUSIONS TS are at increased risk of UPCs compared with NTS, but this risk is still largely borne by a minority of TS. UPCs seem to be a reasonable proxy for malpractice risk, so targeted interventions for TS associated with disproportionate shares of UPCs may reduce patient dissatisfaction and, perhaps, malpractice claims.

Glycemic control in critically ill surgical patients: risks and benefits

Glucose metabolism in humans is exceedingly complex. At baseline, it is controlled by elaborate signaling mechanisms, and these mechanisms are profoundly altered by the surge of catecholamines and cytokines associated with acute postsurgical and post-traumatic stress. These alterations in signaling mechanisms result in hyperglycemia; although this hyperglycemia can start very rapidly after the traumatic or surgical insult, it can persist during the entire period of critical illness and even afterward. Numerous randomized clinical trials have been conducted to determine if hyperglycemia is associated with increased mortality in surgical patients. These studies have had different conclusions that are difficult to interpret in light of differences in study methodology, but there is certainly ample evidence that inadequately controlled hyperglycemia causes harm due to increased infectious morbidity, and possibly increased mortality. As we have become more proficient in controlling hyperglycemia, the concept of insulin resistance, determined as the amount of insulin required to achieve hyperglycemia, has come to the fore. Insulin resistance is not a static concept, and may change before significant events such as infection. Patients with elevated and persistent insulin resistance have been demonstrated to suffer increased infectious morbidity and mortality, albeit in nonrandomized studies. Along with insulin resistance, the concept of glycemic variability, the amount of variation in serum blood glucose over time, has also become relevant; increased variability has been associated with hypoglycemia and mortality. Both of these risks can result from aggressive insulin therapy, and glycemic control protocols must be appropriately planned and implemented to avoid hypo- glycemia and excessive externally induced variability. Computer-assisted protocols may be of significant benefit in optimizing glycemic control. The most recent recommendations available are to keep serum blood glucose levels below 150 mg/dL and to avoid hypoglycemia.

PD63-02 COMPLIANCE WITH AUA GUIDELINES WITH EXCRETORY PHASE IMAGING FOR EVALUATION OF HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

INTRODUCTION AND OBJECTIVES: In our initial review of the Trauma Outcomes and Urogenital Health (TOUGH) cohort, we identified 423 male US service members (SMs) who sustained penile injuries (PI) while deployed in support of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF). Conventional penile reconstruction is challenged by the unique structure and function of the penile tissues. Thus, penile transplantation is being investigated as a potential means for penile replacement after severe PI. We have made the clinical observation that many SMs who sustained severe PI during OIF/OEF presented with complex polytrauma which may have excluded them from enrollment in existing penile transplantation protocols. The objective of this study was to evaluate the injury patterns among members of the TOUGH cohort who sustained PI with a focus on comorbid conditions which may impact candidacy for penile transplantation. METHODS: The previously identified members of the TOUGH cohort who sustained PI were further characterized based on injury severity as well as the presence of comorbid conditions which may impact eligibility for penile transplantation. Severe PI was defined as an Abbreviated Injury Scale severity of 3 or greater (cutaneous avulsion, laceration through glans/cavernosum/urethra, or partial/total penectomy). Five comorbid conditions were identified which may negatively impact penile transplant candidacy: traumatic brain injury (TBI), massive blood transfusion, colorectal injury, pelvic fracture, and extremity amputation(s). SMs with severe PI were stratified by the number of comorbid conditions diagnosed. RESULTS: Among the 423 men with PI identified in the TOUGH cohort, 86 (20.3%) sustained severe PI. SMs with severe PI were largely young (median age: 23) and injured during battle (n1⁄481; 94%) by explosive mechanisms (n1⁄477; 90%) resulting in severe polytrauma (median ISS1⁄429). Comorbid conditions which could impact penile transplantation candidacy were common, including massive transfusion (n1⁄456; 65%), lower extremity amputation(s) (n1⁄455; 64%), TBI (n1⁄434; 40%), colorectal injury (n1⁄429; 34%), and pelvic fracture (n1⁄427; 31%). Overall, 83% of SMs (n1⁄471) had at least one of these conditions and 47% (n1⁄441) had 3. CONCLUSIONS: Severe PI was relatively rare during OIF/OEF. Life-threatening polytrauma was common and nearly all SMs with severe PI had comorbid immunologic, physical, and/or neurologic diagnoses which could disqualify them from penile transplantation given the current restrictions identified in existing transplant protocols. Source of Funding: none; The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army or the Department of Defense or the U.S. Government.

MP79-01 NEPHRECTOMY AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

Health Network. Dr Rupal Gupta, medical editor at Kids Health, Dr Carlos Estrada from Boston Children’s Hospital, and Dr T. Ernesto Figueroa from Nemours/AI duPont Hospital for Children were the facilitators of the chat. The search tags included #khchat and #TesticularTorsion. It lasted one hour, and was joined by 90 people producing 660 tweets and 33,750,157 impressions on this subject. Throughout the chat, various questions were posed by Kids Health that were answered by the facilitators to provide information and generate discussion. CONCLUSIONS: Social media provides an outlet to discuss significant healthcare topics and serves as a unique way to reach a younger audience. Tweet chats in particular are a successful way in pediatric urology to promote awareness of important topics.