Journal of Trauma and Acute Care Surgery最新文献

Background: Health literacy (HL) is the ability to understand and use information for health decisions. Low HL is associated with poor surgical outcomes and disparities in care, but its impact on acute care surgery (ACS) populations is poorly understood. Health literacy is important in ACS populations where patients have complex medical needs, limited preoperative communication, and significant social vulnerabilities. We performed a systematic review aimed at assessing HL-related outcomes in ACS populations, evaluating the quality of existing evidence and examining equity-related variable collection using the PROGRESS+ framework.

Methods: PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were queried up to May 25, 2023, and studies evaluating HL in ACS populations were included. Two reviewers independently extracted relevant articles and performed risk of bias analyses. Studies evaluating the association between HL and patient outcomes in ACS populations were included. Equity-related reporting within studies was evaluated with the PROGRESS+ checklist. Of 1,369 abstracts identified, 10 studies remained after full-text review.

Results: All included studies were observational with a median patient enrollment of 128 (interquartile range, 58-199). Low HL was associated with worse knowledge of injuries, decreased adherence, and poorer follow-up in seven studies (70%). Moderate to high risk of bias was found in six studies (60%). No study reported all 10 PROGRESS+ variables, and 4 studies (40%) reported 3 or fewer.

Conclusion: While studies evaluating HL-related outcomes in ACS populations are few, many found adverse outcomes related to low HL. However, these studies frequently lacked validated measures, comprehensive variable reporting, and consideration of social factors, with many at a high risk of bias. High-quality research using standardized HL instruments and improved equity data collection is needed to inform interventions and improve outcomes.

Level of evidence: Systematic Review/Meta analyses; Level IV.

Background: Chronic pain, anxiety, depression, and posttraumatic stress disorder (PTSD) are frequently seen after traumatic injury. Ketamine infusions used to treat acute pain may decrease the risk of chronic pain and improve psychological outcomes of injured patients. We hypothesized patients receiving ketamine would have a lower incidence of chronic pain, anxiety, depression, and PTSD.

Methods: A prospective, randomized, double-blind placebo-controlled trial of severely injured (Injury Severity Score ≥15) adult patients (age, 18-64 years) admitted to a Level 1 trauma center was conducted. Exclusion criteria included pregnancy and chronic opiate use. All patients were prescribed a patient-controlled analgesia and randomized to either adjustable dose ketamine (ADK) starting at 3 μg/kg/min or an equivalent rate of 0.9% normal saline. Quality of life (QoL) outcomes were measured using Depression and Anxiety (Depression Anxiety Stress Scales 21), PTSD (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5), Trauma quality of life (TQOL), and pain (Brief Pain Inventory-Short Form) questionnaires at hospitalization, and 1, 3, and 6 months postdischarge. Linear regression analysis evaluated the relationship between groups and baseline pain and mental health outcomes at each follow-up.

Results: Forty-four of 82 patients (54%) were randomized to ADK. Both groups were similar in demographics, injury mechanisms/severity, and baseline QOL measures. Patients in the ketamine group had significantly less anxiety symptom severity ( p < 0.05) and PTSD ( p < 0.05), with significantly less re-experiencing symptoms (subscale of PTSD) at 3 and 6 months ( p < 0.05).

Conclusion: Ketamine infusion for acute pain treatment in severe traumatic injury may significantly reduce anxiety and PTSD 6 months after injury. This effect may be specific to the memory processes responsible for re-experiencing symptoms. Further research should explore the effects of acute ketamine administration on the neurobiological mechanisms implicated in the development of PTSD, as this could be a novel preventative intervention to improve QoL for injured patients.

Level of evidence/study type: Therapeutic/Care Management; Level I.

Background: Trauma-induced coagulopathy (TIC) has distinct fibrinolytic phenotypes based on viscoelastic testing. The underlying mechanisms behind differences in fibrinolytic responses to trauma are unclear. We hypothesized that plasma proteins crosslinked into fibrin clots by the transglutaminase activity of factor XIII (FXIII) may explain tissue-type plasminogen activator (tPA) responsiveness observed in fibrinolysis shutdown.

Methods: Plasma samples from trauma patients were categorized into four fibrinolytic phenotypes (hyperfibrinolysis, hypofibrinolysis, fibrinolysis shutdown, and physiologic fibrinolysis) based on rapid thromboelastography and tPA-enhanced thromboelastography. Plasma underwent liquid chromatography-mass spectrometry proteomics for substrates of FXIII, evaluation for FXIII concentration/activity, and Western blotting to confirm proteomic findings. In vitro studies assessed cysteine cathepsin-mediated proteolysis of fibrinolytic and clot-related proteins.

Results: Plasma proteomic analysis identified differences in levels of four proteins known to be crosslinked into fibrin in fibrinolysis shutdown patients. Patients with shutdown exhibited significantly higher plasma FXIII activity compared with other phenotypes. Because FXIII crosslinks protease inhibitors to fibrin, we studied inflammatory cysteine cathepsins' ability to degrade fibrinolytic proteins. Cysteine cathepsins degraded coagulation and fibrinolytic proteins in vitro, including plasminogen, tPA, and fibrinogen. Cathepsin L exposure completely disrupted ex vivo fibrin clot formation and impaired fibrinolytic enzyme function, highlighting its potential multifaceted role in TIC pathophysiology.

Conclusion: Elevated FXIII activity and protease inhibitor incorporation into fibrin clots may regulate fibrinolysis shutdown in trauma patients with fibrinolysis shutdown by inhibiting cysteine cathepsin activity. These findings identify FXIII and cysteine cathepsins as possible contributors to TIC that should be studied further.

Introduction: Compensation disparities significantly impact junior faculty, especially trauma surgeons (TSs) facing complex compensation structures. Only 20.3% of TSs think that their compensation is determined objectively, highlighting the importance of understanding compensation metrics. We aim to measure the worth of different trauma-related specialties through total cash compensation (TCC), work relative value units (wRVUs), and TCC/wRVU.

Methods: Total cash compensation, wRVU, and TCC/wRVU data were obtained from Medical Group Management Association from 2010 to 2023 for critical care specialists, orthopedic surgeons, general surgeons, and TSs in academic (Ac) and nonacademic (non-Ac) settings. Z test compared mean values between Ac VERSUS non-Ac annually. Ac/non-Ac ratios were calculated to assess compensation trends.

Results: Academic physicians consistently earned less TCC than non-Ac counterparts, with TSs showing the highest mean difference in 2023 (-$132,941). Academic TSs generated significantly more wRVUs than non-Ac counterparts (2,169-2,886 more annually) through 2018, but this advantage disappeared by 2023. Academic TSs consistently earned less per wRVU, with the most dramatic disadvantage in 2010 (Ac/non-Ac ratio of 0.50). While this improved to 0.82 by 2023, it remained the lowest among all trauma-related specialties (compared with 0.89 for orthopedic surgeons, 1.39 for critical care specialists, and 0.96 for general surgeons).

Conclusion: Our longitudinal study demonstrates that Ac physicians receive lower TCC and TCC/wRVU, even while historically maintaining higher clinical productivity. The traditional justification that lower Ac compensation reflects reduced clinical activity is challenged by our finding that Ac trauma clinicians historically generated more wRVUs. Trauma surgeons face a "double disadvantage," which is being undercompensated relative to both non-Ac TSs and other Ac specialists. Rectifying these compensation inequities is critical to preserving the Ac mission and ensuring excellence in trauma care, education, and research.

Level of evidence: Economic and Value Based Evaluations; Level III.

Background: The American College of Surgeons Committee on Trauma requires that trauma centers have a structured approach to identifying patients at risk for mental health conditions. However, the college does not recommend any specific screening protocol. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) is a validated, 20-question screening instrument used at many trauma centers. This study evaluates the diagnostic performance of a verbal, two-question prescreen based on the PCL-5.

Methods: All traumatically injured patients were screened for posttraumatic stress disorder (PTSD) via a verbal prescreen based on the first two questions of the PCL-5, followed by the PCL-5 itself. Clinicians were encouraged to adapt the language of the prescreen as they felt appropriate but to evaluate for intrusive memories and nightmares. If the patient endorsed any intrusive symptoms, the prescreen was considered positive. The performance of the verbal prescreen was evaluated using the PCL-5 as the standard at multiple score thresholds.

Results: Of the patients analyzed, 268 completed PTSD screening with the prescreen and PCL-5. Of these, 36.6% (98 of 268 patients) screened positive on the prescreen. The sensitivity was 100% (95% confidence interval, 88-100%), and the specificity was 69% (95% confidence interval, 62-76%) for our institutional positive threshold of 30 points on the PCL-5, with a positive predictive value of 21% and a negative predictive value of 100%.

Conclusion: A simple verbal prescreen for intrusive symptoms of PTSD can reduce the number of required PCL-5 screenings by 63% without sacrificing sensitivity. This prescreen increases efficiency of PTSD screening without the need for specialized psychiatric personnel or additional resources.

Level of evidence: Diagnostic Tests or Criteria; Level III.

Abstract: Resuscitative thoracotomy (RT) is a time-critical procedure performed in the setting of traumatic cardiac arrest, primarily to address cardiac tamponade, control intrathoracic bleeding, and reduce infradiaphragmatic blood loss. Advances in trauma care have refined the indications and improved the outcomes of RT in select patient populations. This review focuses on current techniques, indications, outcomes, and future directions. The physiologic objectives are to release pericardial tamponade, repair cardiac injuries, control intrathoracic hemorrhage, perform open cardiac massage, and provide access for aortic cross-clamping and hilar clamping for control of bronchovenous air embolism. Resuscitative thoracotomy is indicated for profound hypotension (systolic blood pressure, <60 mm Hg) or patients with a traumatic cardiac arrest who have required less than 15 minutes of cardiopulmonary resuscitation. Patients with penetrating trauma in extremis, especially with cardiac tamponade, have improved survival with RT (>15%) compared with patients with blunt trauma with RT (<2%). Future directions include refining the indications of RT with the advent of resuscitative endovascular balloon occlusion of the aorta (REBOA), defining futility, establishing the role of extracorporeal membrane oxygenation (ECMO), suspended animation, and evaluating the role of RT in patients who will become organ donors. This review aims to provide an up-to-date, evidence-based overview of RT to guide trauma providers in optimizing patient selection, procedural technique, and informed decision making regarding patient outcomes.