Mohammad Hamidi

Optimal Timing of Initiation of Thromboprophylaxis after Nonoperative Blunt Spinal Trauma: A Propensity-Matched Analysis

BACKGROUNDnPatients with spinal trauma have the highest risk of a venous thromboembolism. Although anticoagulation is recommended, its optimal timing is not well-defined. We aimed to assess the impact of early initiation of thromboprophylaxis in spinal trauma patients who were managed nonoperatively.nnnSTUDY DESIGNnA 2-year (2013 to 2014) analysis of all isolated spinal trauma patients managed nonoperatively who received thromboprophylaxis in the American College of Surgeons Trauma Quality Improvement Program. Patients were divided into 2 groups based on timing of initiation of thromboprophylaxis: early (<48 hours) and late (≥48 hours), and were matched in a 1:1 ratio using propensity score matching for demographic characteristics, admission vitals, injury severity, level of spine injury, and type of prophylaxis. Outcomes were prevalence of deep venous thrombosis (DVT) and pulmonary embolism, packed RBC requirement, and mortality.nnnRESULTSnWe included 20,106 patients, of which 8,552 (early, nxa0= 4,276; late, nxa0= 4,276) were matched. Matched groups were similar in demographic characteristics, vital and injury parameters, and type of prophylaxis. Patients in the early group were less likely to have DVT (1.7% vs 7.6%; p < 0.001) or pulmonary embolism (0.8% vs 2.2%; p < 0.001) develop compared with the late group. In addition, there was no difference in packed RBC requirement (pxa0= 0.61) and mortality (pxa0= 0.49). Patients who received unfractionated heparin had a similar rate of DVT (pxa0= 0.26) and pulmonary embolism (pxa0= 0.35) compared with those who received low-molecular-weight heparin.nnnCONCLUSIONSnIn patients with nonoperative spinal trauma, early initiation of thromboprophylaxis is associated with decreased rates of DVT and pulmonary embolism. In addition, we did not find any association between the type of pharmacologic agents and venous thromboembolism rates. Additional prospective clinical trials should be undertaken to define guidelines for the timing of initiation of thromboprophylaxis.

Day of hospital admission and effect on outcomes: the weekend effect in acute gallstone pancreatitis

BACKGROUNDnThe aim of our study was to evaluate outcomes in patients who are admitted on weekend compared with those admitted on a weekday for acute gallstone pancreatitis.nnnMETHODSnWe performed a 3-y (2010-2012) analysis of the Nationwide Inpatient Sample database. Patients with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included and were divided into two groups: admission on the weekend versus the weekday. Primary outcome measures were time to ERCP, adverse events, and mortality. Secondary outcome measures were hospital length of stay and total cost.nnnRESULTSnA total of 5803 patients with acute gallstone pancreatitis who underwent ERCP were included in our study; of which 22.6% were admitted on the weekend, whereas 77.4% were admitted on a weekday. Mean age was 57xa0±xa018xa0y and 57.1% were female. Within 24xa0h, the rate of ERCP was higher in patients admitted on the weekday compared with those admitted on the weekend (40% versus 24%; Pxa0<xa00.001). Similarly, by 48 h, the rate of ERCP was higher in the weekday group (69% versus 49%, Pxa0<xa00.001). Patients admitted over the weekends had higher complications rate (Pxa0=xa00.03), hospital length of stay (Pxa0<xa00.001), and the total cost of hospitalization (Pxa0<xa00.001) compared with the weekday group with no difference in in-hospital mortality.nnnCONCLUSIONSnPatients admitted on weekends for acute gallstone pancreatitis experience a delay in getting ERCP and have higher complications, prolonged hospital stay, and increased hospital costs compared with those admitted on weekdays.

Can Sarcopenia Quantified by Computer Tomography Scan Predict Adverse Outcomes in Emergency General Surgery

BACKGROUNDnSarcopenia (a decline of skeletal muscle mass) has been identified as a predictor of poor postoperative outcomes. The impact of sarcopenia in emergency general surgery (EGS) remains undetermined. The aim of this study was to evaluate the association between sarcopenia and outcomes after EGS.nnnMETHODSnA 3-y (2012-15) review of all EGS patients aged ≥45 y was presented to ourxa0institution. Patients who underwent computer tomography-abdomen were included. Sarcopenia was defined as the lowest sex-specific quartile of total psoasxa0index (computer tomography-measured psoas area normalized for body surfacexa0area). Patients were divided into sarcopenic (SA) and nonsarcopenic. Primary outcome measures were in-hospital complications, hospital-length of stay [h-LOS], intensive care unit-length of stay, adverse discharge disposition, and in-hospital mortality. Our secondary outcome measures were 30-d complications, readmissions, and mortality.nnnRESULTSnFour hundred fifty-two patients undergoing EGS were included. Mean age wasxa058xa0±xa08.7xa0y, and 60% were males. Hundred thirteen patients were categorized as SA.xa0Compared to nonsarcopenic, SA patients had higher rates of minor complications (28% versus 17%, Pxa0=xa00.01), longer hospital-length of stay (7d versus 5d, Pxa0=xa00.02), andxa0were more likely to be discharged to skilled nursing facility/Rehab (35% versus 17%, Pxa0=xa00.01). There was no difference between the two groups regarding major complications, intensive care unit-length of stay, mortality, and 30-d outcomes. On regression analysis, sarcopenia was an independent predictor of minor complications (OR 1.8 [1.6-3.7]) and discharge to rehab/SNIF (OR: 1.9 [1.5-3.2]). However, there was no association with major complications, mortality, 30-d complications, readmissions, and mortality.nnnCONCLUSIONSnSarcopenia is an independent predictor of minor postoperative complications, prolonged hospital-length of stay, and an adverse discharge disposition in patients undergoing EGS. Identifying SA EGS patients will improve both resource allocation and discussion about the patients prognosis between physicians, patients, and their families.

Outcomes After Massive Transfusion in Trauma Patients: Variability Among Trauma Centers

BACKGROUNDnExsanguinating trauma patients often require massive blood transfusion (defined as transfusion of 10 or more pRBC units within first 24xa0h). The aim of our study is to assess the outcomes of trauma patients receiving massive transfusion at different levels of trauma centers.nnnMETHODSnTwo-y (2013-2014) retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients who received massive transfusion (MT) of blood. Outcome measures were mortality, hospital length of stay, intensive care unit-free and ventilator-free days, blood products received, and complications.nnnRESULTSnWe analyzed a total of 416,957 patients, of which 2776 met the inclusion criteria and included in the study. Mean age was 40.6xa0±xa020xa0y, 78.3% were males and 33.1% of the injuries were penetrating. Median injury severity score [IQR] was 29 [18-40], median [IQR] Glasgow Coma Scale 10[4-15]. Mean packed red blood cells transfusion in the first 24xa0h was 20xa0±xa013 units and mean plasma transfusion was 13xa0±xa011 units. Overall in-hospital mortality was 43.5%. Receiving MT in level I trauma center was independently associated with lower rates of mortality (odds ratio [OR]: 0.75 [0.46-0.96], Pxa0<xa00.001). Higher injury severity score (OR: 1.020 [1.010-1.030], Pxa0<xa00.001) and increased units of packed red blood cells transfused (OR: 1.067 [1.041-1.093], Pxa0<xa00.001) were independently associated with increased mortality. However, there was no association between teaching status, age, gender, emergency department vitals, and units of plasma transfused.nnnCONCLUSIONSnHemorrhage continues to remain one of the most common cause of death after trauma. Almost half of the patients who received massive transfusion died. Patients who receive massive blood transfusion in a level I trauma centers have improved survival compared with level II trauma centers.

Direct Oral Anticoagulants vs Low-Molecular–Weight Heparin for Thromboprophylaxis in Nonoperative Pelvic Fractures

BACKGROUNDnPatients with pelvic fractures are prone to venous thromboembolic (VTE) complications. Recent literature shows superiority of direct oral anticoagulants (DOACs) over low-molecular-weight heparin (LMWH) for thromboprophylaxis in patients undergoing orthopaedic operations. The aim of our study was to compare in-hospital outcomes for DOACs vs LMWH in patients with nonoperative pelvic fractures.nnnSTUDY DESIGNnWe performed a 2-year (2015 to 2016) analysis of the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database. We included all adult patients with isolated blunt pelvic fractures who were managed nonoperatively and received thromboprophylaxis with either LMWH or DOACs (Factor-Xa inhibitor or direct thrombin inhibitor). Patients were divided into 2 groups based on receipt of DOACs vs LMWH and were propensity-score-matched in a 1:2 ratio to control for possible confounding factors. Primary outcomes were deep venous thrombosis (DVT) and/or pulmonary embolism (PE). Secondary outcomes were pRBC transfusions, intervention for hemorrhage control, and in-hospital mortality after initiation of thromboprophylaxis.nnnRESULTSnWe identified 20,692 patients with pelvic fractures. There were 7,312 patients with isolated pelvic fractures included, 852 of whom were matched (DOACs: 284; LMWH: 568). Mean age was 43.2 ± 15 years, median Injury Severity Score was 14 (range 10 to 18). Matched groups were similar in demographics, vital signs, injury parameters, and timing of initiation of thromboprophylaxis. Overall, 5.2% of patients had DVT, 1.4% PE, and 1.3% died. Patients who received DOACs were less likely to develop DVT (1.8% vs 6.9%, p < 0.01) compared with LMWH. There was no difference in PE (pxa0= 0.85) or in-hospital mortality (pxa0= 0.79) between the 2 groups. Similarly, there was no difference in post-prophylaxis blood transfusion, and post-prophylaxis intervention for hemorrhage control.nnnCONCLUSIONSnIn patients with nonoperative pelvic fractures, DOACs were associated with a reduced rate of DVT vs LMWH without increasing the risk of bleeding complications. No association was found between the type of thromboprophylactic agent and rates of PE or in-hospital mortality.

Oral Xa Inhibitors versus low molecular weight heparin for thromboprophylaxis after nonoperative spine trauma

BACKGROUNDnThromboprophylaxis with oral Xa inhibitors (Xa-Inh) are recommended after major orthopedic operation; however, its role in spine trauma is not well-defined. The aim of our study was to assess the impact of Xa-Inh in spinal trauma patients managed nonoperatively.nnnMETHODSnA 4-y (2013-2016) review of the Trauma Quality Improvement Program database. We included all patients with an isolated spine trauma (Spine-abbreviated injury scale ≥3 and other-abbreviated injury scale <3) who were managed nonoperatively and received thromboprophylaxis with either low molecular weight heparin (LMWH) or Xa-Inh. Patients were divided into two groups based on the thromboprophylactic agent received: Xa-Inh and LMWH and were matched in a 1:2 ratio using propensity score matching for demographics, vitals and injury parameters, and level of spine injury. Outcomes were rates of deep venous thrombosis, pulmonary embolism, and mortality.nnnRESULTSnWe analyzed a total of 58,936 patients, of which 1056 patients (LMWH: 704, Xa-Inh: 352) were matched. Matched groups were similar in demographics, vital and injury parameters, length of hospital stay (Pxa0=xa00.31), or time to thromboprophylaxis (Pxa0=xa00.79). Patients who received Xa-Inh were less likely to develop a deep venous thrombosis (2.3% versus 5.7%, Pxa0<xa00.01). There were no differences in the rate of pulmonary embolism (Pxa0=xa00.73), postprophylaxis packed red blood cells transfusions (Pxa0=xa00.79), postprophylaxis surgical decompression of spinal column (Pxa0=xa00.75), and mortality rate (Pxa0=xa00.77).nnnCONCLUSIONSnOral Xa-Inh seems to be more effective as prophylactic pharmacologic agent for the prevention of deep venous thrombosis in patients with nonoperative spinal trauma compared to LMWH. The two drugs had similar safety profile. Further prospective trials should be performed to change current guidelines.

Changing Epidemiology of the American Population

The changing epidemiology of the geriatric population in the United States has diverse social, medical, and financial implications that will continue to expand over the next few decades. According to the US Census Bureau, 20% of the US population will be 65xa0years or older by 2030 and more than 50% will eventually belong to a minority group. These changes are expected to be accompanied by several effects on the geriatric populations demographics, injury characteristics, surgical interventions, and the cost of caring for the geriatric population, which will ultimately broaden the financial burden.

A modified frailty index predicts adverse outcomes among patients with colon cancer undergoing surgical intervention

INTRODUCTIONnAssessing outcomes in patients with colon cancer (CC) undergoing surgical intervention is challenging. Frailty has been as established tool for assessing patient outcomes. The aim was of this study was to assess role of frailty in patients with CC.nnnMETHODSnNational estimates for patients with CC were abstracted from the National Inpatient Sample (NIS) database (2011). Frailty was calculated using a 11 variable CCFI. Patient was stratified as frail (FL) (mFI≥0.25) and non-frail (Non-FL). Outcome measures were: in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS), discharge disposition, and mortality. Regression analysis was performed.nnnRESULTSnA total of 53,652 patients with CC who underwent surgery were analyzed. The mean age was 69u202f±u202f19 years with 62% males and mean CCFI being 0.13. 34% of patients were frail. 22.3% patients had in-hospital complications and mortality rate was 3.2%. Frail patients were more likely to have in-hospital complications (pu202f=u202f0.001), longer hospital LOS (pu202f=u202f0.001), more likely to be discharged to a facility (pu202f=u202f0.001). On regression analysis after controlling for age, gender, type of procedure, hospital status, insurance status, frail status was independently associated with in-hospital complications (OR[95% CI]: 1.8[1.1-2.9], pu202f=u202f0.035) and adverse discharge disposition (OR[95% CI]: 1.3[1.08-3.5], pu202f=u202f0.043).nnnCONCLUSIONnFrailty status is an independent predictor of adverse outcomes (complications, discharge disposition, and LOS) in CC patient undergoing surgical intervention. Age was not independently associated with outcome and had poor correlation with frailty status. Pre-operative assessment of frailty in CC patient may help early identifications and risk stratification to help improve outcomes and discharge planning.

Prospective evaluation of frailty and functional independence in older adult trauma patients

BACKGROUNDnThe aim of our study was to assess the association between frailty and functional status in geriatric trauma patients.nnnMETHODSn3-year(2013-2015) prospective analysis and included all geriatric trauma patients(≥65y) discharged to a single rehabilitation center from our level-I trauma center. Frailty was measured using Trauma-Specific-Frailty-Index(TSFI) while Functional status was assessed using functional-independence-measure(FIM) at admission and discharge from rehabilitation center. Multivariate linear regression analysis was performed.nnnRESULTSn267 patients were enrolled. Mean age was 76.9u202f±u202f7.1y, 63.6% were males. Overall, 22.8% were frail, and 37.4% were pre-frail. On linear regression, higher motor-FIM, higher cognitive-FIM scores at admission, and longer length-of-stay at rehab were independently associated with increased discharge FIM score. While, ISS(injury-severity-score), pre-frail and frail status were negatively correlated with FIM gain.nnnCONCLUSIONnFrail patients were less likely to recover to their baseline functional status compared with non-frail patients. Early focused intervention in frail elderly patients is warranted to improve functional status in this population.

The burden of excess length of stay in trauma patients

BACKGROUNDnDisposition of trauma patients frequently results in excessive hospital-stay. The aim of this study was to assess the risk of developing complications due to excessive stay in the hospital.nnnMETHODSnOver a period of 4 years (2012-2015) we analyzed all trauma patients with hospital length-of-stay (h-LOS) >30 days. Outcome measures were complications after termination of medical care.nnnRESULTSn416 patients were identified having h-LOS>30 days of which 61.0% (254) had an excess hospital stay and were included. The most common causes of excess hospital stay were placement in SNiF followed by placement in Inpatient-Rehabilitation. Excessive hospital-stay was independently associated with the development of complications (pu202f=u202f0.004). Each excess day in the hospital after completion of medical care was associated with 5% higher odds of complications (OR [95%CI]: 1.05[1.02-1.09]) independent of presenting condition of the patient.nnnCONCLUSIONnEach extra day spent in the hospital after completion of medical care was associated with higher odds of developing complications.