Epidemiology and outcomes of multiple organ dysfunction syndrome following pediatric trauma

alexandrossfakianakis shared this article with you from Inoreader Epidemiology and outcomes of multiple organ dysfunction syndrome following pediatric trauma via Journal of Trauma and Acute Care Surgery - Current Issue BACKGROUND Existing studies have found a low prevalence of multiple organ dysfunction syndrome (MODS) in pediatric trauma patients, typically applying adult criteria to single-center pediatric cohorts. We used pediatric criteria to determine the prevalence, risk factors, and outcomes of MODS among critically injured children in a national pediatric intensive care unit (PICU) database. METHODS We conducted a retrospective cohort study of PICU patients 1 month to 17 years with traumatic injury in the Virtual Pediatric Systems, LLC database from 2009 to 2017. We used International Pediatric Sepsis Consensus Conference criteria to identify MODS on Day 1 of PICU admission and estimated the risk of mortality and poor functional outcome (Pediatric Overall/Cerebral Performance Category ≥3 with ≥1 point worsening from baseline) for MODS and for each type of organ dysfunction using generalized linear Poisson regression adjusted for age, comorbidities, injury type and mechanism, and postoperative status. RESULTS Multiple organ dysfunction syndrome was present on PICU Day 1 in 23.1% of 37,177 trauma patients (n = 8,592), with highest risk among patients with injuries associated with drowning, asphyxiation, and abuse. Pediatric intensive care unit mortality was 20.1% among patients with MODS versus 0.5% among patients without MODS (adjusted relative risk, 32.3; 95% confidence interval, 24.1–43.4). Mortality ranged from 1.5% for one dysfunctional organ system to 69.1% for four or more organ systems and was highest among patients with hematologic dysfunction (43.3%) or renal dysfunction (29.6%). Death or poor functional outcome occurred in 46.7% of MODS patients versus 8.3% of patients without MODS (adjusted relative risk, 4.3; 95% confidence interval 3.4–5.3). CONCLUSION Multiple organ dysfunction syndrome occurs more frequently following pediatric trauma than previously reported and is associated with high risk of morbidity and mortality. Based on existing literature using identical methodology, both the prevalence and mortality associated with MODS are higher among trauma patients than the general PICU population. Consideration of early organ dysfunction in addition to injury severity may aid prognostication following pediatric trauma. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III. View on Web

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Lucky number 13: Association between center-specific chest wall stabilization volumes and patient outcomes

alexandrossfakianakis shared this article with you from Inoreader Lucky number 13: Association between center-specific chest wall stabilization volumes and patient outcomes via Journal of Trauma and Acute Care Surgery - Current Issue BACKGROUND Chest wall stabilization (CWS) improves outcomes for patients with chest wall injury (CWI). We hypothesized that patients treated at centers with higher annual CWS volumes experience superior outcomes. METHODS A retrospective study of adults with acute CWI undergoing surgical stabilization of rib or sternal fractures within the 2019 Trauma Quality Improvement Program database, excluding those with 24-hour mortality or any Abbreviated Injury Scale body region of six, was conducted. Hospitals were grouped in quartiles by annual CWS volume. Our primary outcome was a composite of in-hospital mortality, ventilator-associated pneumonia, acute respiratory distress syndrome, sepsis, and unplanned intubation or intensive care unit readmission. Regression was controlled for age, sex, Injury Severity Scale, flail chest, medical comorbidities, and Abbreviated Injury Scale chest. We performed cut-point analysis and compared patient outcomes from high- and low-volume centers. RESULTS We included 3,207 patients undergoing CWS at 430 hospitals with annual volumes ranging from 1 to 66. There were no differences between groups in age, sex, or Injury Severity Scale. Patients in the highest volume quartile (Q4) experienced significantly lower rates of the primary outcome (Q4, 14%; Q3, 18.4%; Q2, 17.4%; Q1, 22.1%) and significantly shorter hospital and intensive care unit lengths of stay. Q4 versus Q1 had lower adjusted odds of the primary outcome (odds ratio, 0.58; 95% confidence interval, 0.43–0.80). An optimal cut point of 12.5 procedures annually was used to define high- and low-volume centers. Patients treated at high-volume centers experienced significantly lower rates of the primary composite outcome, in-hospital mortality, and deep venous thrombosis with shorter lengths of stay and higher rates of home discharge. CONCLUSION Center-specific CWS volume is associated with superior in-hospital patient outcomes. These findings support efforts to establish CWI centers of excellence. Further investigation should explore the impact of center-specific volume on patient-reported outcomes including pain and postdischarge quality of life. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III. View on Web

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Redefining the costal margin: A pilot study

alexandrossfakianakis shared this article with you from Inoreader Redefining the costal margin: A pilot study via Journal of Trauma and Acute Care Surgery - Current Issue BACKGROUND Classical teaching of rib anatomy contends that the false ribs (7th to 10th) fuse anteriorly to form the costal margin of the chest. Slipped rib syndrome consists of false rib subluxation into the thorax with symptomatic impingement of the intercostal nerve. We sought to determine the incidence of this anatomic finding through anatomic study of the costal margin. METHODS Cadavers were evaluated for mobility and attachment of the ninth and tenth ribs. Experienced anatomists and chest wall surgeons conducted a standardized dissection and assessed rib tip mobility using predefined criteria. Videos of dissections were submitted to a single investigator who reviewed the findings. RESULTS Costal margins of 40 cadavers (45% male) were evaluated bilaterally. The average age was 83 years ± 11 years. The ninth rib was found to be attached to the eighth rib 100% of the time by an interchondral cartilaginous attachment along the body of the eighth and ninth ribs. Internal subluxation was noted in 19% (15 of 80), and the tip of the rib was mobile in 86% (69 of 80) evaluations. The tenth rib was attached to the ninth rib in 18%(14/80). A "floating" 10th rib was noted in 59% (47 of 80) of specimens. Subluxation was noted in 33% (26 of 60). Half of the ribs that subluxed moved medially to the ninth rib and half moved externally. An upwardly hooked tip was noted in 10% (8 of 80). Ribs with a hooked tip subluxed in 63% (5 of 8), and all of these ribs (5 of 5) moved to the interior of the chest (p = 0.020). CONCLUSION The ninth rib is commonly attached to the eighth rib, but the tenth rib is often not attached to the ninth rib. Most commonly, the tenth rib is a "floating" rib. Internal subluxation of the tenth rib as well as the presence of a hooked tip may predispose individuals to the development of "slipped rib syndrome." LEVEL OF EVIDENCE Diagnostic Tests or Criteria; Level III. View on Web

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A method for identifying the learning curve for the surgical stabilization of rib fractures

alexandrossfakianakis shared this article with you from Inoreader A method for identifying the learning curve for the surgical stabilization of rib fractures via Journal of Trauma and Acute Care Surgery - Current Issue BACKGROUND Surgical stabilization of rib fractures (SSRF) is an accepted efficacious treatment modality for patients with severe chest wall injuries. Despite increased adoption of SSRF, surgical learning curves are unknown. We hypothesized intraoperative duration could define individual SSRF learning curves. METHODS Consecutive SSRF operations between January 2017 and December 2021 at a single institution were reviewed. Operative time, as measured from incision until skin closure, was evaluated by cumulative sum methodology using a range of acceptable "missteps" to determine the learning curves. Misstep was defined by extrapolation of accumulated operative time data. RESULTS Eighty-three patients underwent SSRF by three surgeons during this retrospective review. Average operative times ranged from 135 minutes for two plates to 247 minutes for seven plates. Using polynomial regression of average operative times, 75 minutes for general procedural requirements plus 35 minutes per plate were derived as the anticipated operative times per procedure. Cumulative sum analyses using 5%, 10%, 15%, and 20% incident rates for not meeting expected operative times, or "missteps" were used. An institutional learning curve between 15 and 55 SSRF operations was identified assuming a 90% performance rate. An individual learning curve of 15 to 20 operations assuming a 90% performance rate was observed. After this period, operative times stabilized or decreased for surgeons A, B, and C. CONCLUSION The institutional and individual surgeon learning curves for SSRF appears to steadily improve after 15 to 20 operations using operative time as a surrogate for performance. The implementation of SSRF programs by trauma/acute care surgeons is feasible with an attainable learning curve. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV. View on Web

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Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey

alexandrossfakianakis shared this article with you from Inoreader Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey via Journal of Trauma and Acute Care Surgery - Current Issue BACKGROUND In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes. METHODS Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category. RESULTS Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions. CONCLUSION This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research. LEVEL OF EVIDENCE Diagnostic Tests or Criteria; Level IV. View on Web

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Surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures following cardiopulmonary resuscitation: An international, retrospective matched case-control study

alexandrossfakianakis shared this article with you from Inoreader Surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures following cardiopulmonary resuscitation: An international, retrospective matched case-control study via Journal of Trauma and Acute Care Surgery - Current Issue BACKGROUND The presence of six or more rib fractures or a displaced rib fracture due to cardiopulmonary resuscitation (CPR) has been associated with longer hospital and intensive care unit (ICU) length of stay (LOS). Evidence on the effect of surgical stabilization of rib fractures (SSRF) following CPR is limited. This study aimed to evaluate outcomes after SSRF versus nonoperative management in patients with multiple rib fractures after CPR. METHODS An international, retrospective study was performed in patients who underwent SSRF or nonoperative management for multiple rib fractures following CPR between January 1, 2012, and July 31, 2020. Patients who underwent SSRF were matched to nonoperative controls by cardiac arrest location and cause, rib fracture pattern, and age. The primary outcome was ICU LOS. RESULTS Thirty-nine operatively treated patient were matched to 66 nonoperatively managed controls with comparable CPR-related characteristics. Patients who underwent SSRF more often had displaced rib fractures (n = 28 [72%] vs. n = 31 [47%]; p = 0.015) and a higher median number of displaced ribs (2 [P25–P75, 0–3] vs. 0 [P25–P75, 0–3]; p = 0.014). Surgical stabilization of rib fractures was performed at a median of 5 days (P25–P75, 3–8 days) after CPR. In the nonoperative group, a rib fixation specialist was consulted in 14 patients (21%). The ICU LOS was longer in the SSRF group (13 days [P25–P75, 9–23 days] vs. 9 days [P25–P75, 5–15 days]; p = 0.004). Mechanical ventilator-free days, hospital LOS, thoracic complications, and mortality were similar. CONCLUSION Despite matching, those who underwent SSRF over nonoperative management for multiple rib fractures following CPR had more severe consequential chest wall injury and a longer ICU LOS. A benefit of SSRF on in-hospital outcomes could not be demonstrated. A low consultation rate for rib fixation in the nonoperative group indicates that the consideration to perform SSRF in this population might be associated with other nonradiographic or injury-related variables. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III. View on Web

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Great Toe Transplantation

alexandrossfakianakis shared this article with you from Inoreader Great Toe Transplantation via Seminars in Plastic Surgery Semin Plast Surg DOI: 10.1055/s-0042-1758689 Despite being relatively uncommon in the general population, thumb amputations cause severe disability. More than 3,300 thumb amputations occurred in the United States. The thumb makes up around 40% of the function of the hand. Therefore, losing it would result in significant medical, hospital, and societal costs. Thumb reconstruction surgery's primary goal is to restore grip strength, including the range of motion, fine and tripod pinch, power grasp, strength, and sensibility, while secondary goals include restoring hand aesthetics. In cases of thumb replantation, like-for-like replacement is possible; however, when thumb replantation is not possible, great toe-to-hand transplantation is the best available reconstruction. When compared with other reconstructive options such as osteoplastic thumb reconstruction, pollicization, second toe transplantation, and the use of a thumb prosthesis, great toe transplantation provides superior function and aesthetics. For restoring pinch, sensitivity, strength, and aesthetics of the hand with well-tolerated donor site morbidity, toe to thumb transplantation is regarded as the gold standard. [...] Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Article in Thieme eJournals: < a href="https://www.thieme-connect.com/products/ejournals/issue/eFirst/10.1055/s-00000051" target="_blank" rel="noopener" class="underlink bluelink" tabindex="-1">Table of contents  |  Abstract  |  Full text View on Web

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