Journal of Trauma and Acute Care Surgery最新文献

Background: Vascular surgery board eligibility may be secured through 5+0 integrated programs (IV) as well as 5+2 general surgery/vascular fellowship pathway (VF). We hypothesized that IV graduates accrue less experience relevant to vascular trauma than VF graduates. We assessed the first decade of IV graduate experience and compared it to contemporaneous VF graduates.

Methods: The 2013-2022 Accreditation Council for Graduate Medical Education case log data were collected for IV and VF graduates. Vascular fellows' data were combined with synchronousgeneral surgery residency data. Open vascular cases were classed as cerebrovascular, upper extremity, thoracic, abdominopelvic, infrainguinal, and infrapopliteal. Nonvascular open cases were categorized as neck, thoracic, and abdominopelvic. Nonoperative trauma and critical care data were recorded.

Results: There were 1,224 VF and 397 IV graduates. In 2012, 8.3% of graduating vascular surgeons trained in IV programs. By 2022, this proportion was 32.6%. The number of IV programs increased by 4.4 programs per year over the study period ( p < 0.05), whereas VF programs remained unchanged. Integrated vascular chiefs logged significantly more lower extremity cases, and VFs logged more upper extremity cases ( p < 0.05). IV graduates reported a fraction of the VF open nonvascular cases. Integrated vascular graduates logged 5% of the abdominopelvic, 18% of the thoracic, and 3% of the neck cases of VFs ( p < 0.05). Vascular fellows' critical care and nonoperative trauma were each higher than those of IV fellows ( p < 0.05). Integrated vascular graduates logged six vascular repairs for every vascular exposure.

Conclusion: The proportion of vascular surgeons trained through IV programs has nearly quadrupled. Integrated vascular graduates have a fraction of the experience in critical care, trauma, and nonvascular surgery compared with VF graduates. Relative inexperience with open surgical anatomy and with critically ill patients may limit IV graduates' ability to care for the patient with vascular trauma.

Level of evidence: Diagnostic Test/Criteria; Level IV.

Background: Early identification of individuals at risk of functional impairment after trauma is crucial for the timely clinical decision-making and intervention to improve reintegration into the society. This study aimed to develop and validate models for predicting new-onset functional impairment after trauma using predictors that are routinely collected within 2 days of hospital admission.

Methods: In this multicenter retrospective cohort study of acute care hospitals in Japan, we identified adult patients with trauma with independence in carrying out activities of daily living before hospitalization, treated in the intensive or high-dependency care unit, and survived for at least 2 days between April 2008 and September 2023. The primary outcome was functional impairment defined as Barthel Index ≤60 at hospital discharge. In the internal validation data set (between April 2008 and August 2022), using the routinely collected 129 candidate predictors within 2 days of admission, we trained and tuned the four conventional and machine learning models with repeated random subsampling cross-validation. We measured the performance of these models in the temporal validation data set (between September 2022 and September 2023). We also computed the importance of each predictor variable in our model.

Results: We identified 8,529 eligible patients. Functional impairment at discharge was observed in 41% of the patients (n = 3,506/8,529). In the temporal validation data set, all four models showed moderate discrimination ability, with areas under the curve above 0.79, and extreme gradient boosting showing the best performance (0.83). In the variable importance analyses, age was the most important predictor, followed by consciousness, severity score, cervical spinal cord injury, mild dementia, and serum albumin level at admission.

Conclusion: We successfully developed early prediction models for patients with trauma with new-onset functional impairment at discharge that achieved high predictive performance using routinely collected data within 2 days of hospital admission.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Emergency department (ED) pediatric readiness has been associated with lower mortality for injured children but has historically been suboptimal in nonpediatric trauma centers. Over the past decade, the National Pediatric Readiness Project (NPRP) has invested resources in improving ED pediatric readiness. This study aimed to quantify current trauma center pediatric readiness and identify associations with center-level characteristics to target further efforts to guide improvement.

Methods: The study cohort included all centers that responded to the 2021 NPRP national assessment and contributed data to the National Trauma Data Bank (NTDB) the same calendar year. Center characteristics and pediatric (0-15 years) volume from the NTDB were linked to weighted pediatric readiness scores (wPRSs) obtained from the NPRP assessment. Univariate and multivariable analyses were used to determine associations between wPRS and trauma center type as well as center-level facility characteristics.

Results: The wPRS was reported for 77% (749 of 973) of centers that contributed to the NTDB. Emergency department pediatric readiness was highest in American College of Surgeons level 1 pediatric trauma centers, but wPRS in the highest quartile was seen among all adult and pediatric trauma center types. Independent predictors of high wPRS included American College of Surgeons level 1 pediatric trauma center verification, pediatric trauma volume, and the presence of a pediatric intensive care unit. Higher-level adult trauma centers and pediatric trauma centers were more likely to have pediatric-specific physician requirements, pediatric emergency care coordinators, and pediatric quality improvement initiatives.

Conclusion: Emergency department pediatric readiness in trauma centers remains variable and is predictably lower in centers that lack inpatient resources. There is, however, no aspect of ED pediatric readiness that is constrained to high-level pediatric facilities, and a highest quartile wPRS was achieved in all types of adult centers in our study. Ongoing efforts to improve pediatric readiness for initial stabilization at nonpediatric centers are needed, particularly in centers that routinely transfer children out.

Level of evidence: Prognostic and Epidemiological; Level III.

Background: Cell-free hemoglobin (CFH) and free heme are potent mediators of endotheliopathy and organ injury in sepsis, but their roles in other hemolytic pathologies are not well-defined. A prime example is trauma where early hemolysis may initiate damage and predict outcome. Here, we investigated the presence of plasma CFH, heme, and their major scavengers after traumatic injury.

Methods: Adult patients who presented as highest-level activations were prospectively enrolled at a level 1 trauma center between 2021 and 2023. Venous blood was collected upon arrival (pretransfusion) and 6, 12, and 24 hours after admittance for quantification of CFH, haptoglobin, heme, and hemopexin.

Results: We studied 119 mostly male subjects (101:18) with a median age of 48 years (interquartile range [IQR], 31-64 years) and an Injury Severity Score of 22 (IQR, 11-29); the majority had suffered blunt force trauma. The 28-day mortality rate was 11%. Cell-free hemoglobin was high upon emergency department arrival (10.9 μM; IQR, 6.8-17.6) and then declined but remained elevated compared with normative levels during the monitoring period (>5 vs. ~0.2 μM). The initial drop in CFH was attributed to haptoglobin binding and clearance. Notably, there was a subgroup of patients with two- to threefold higher levels of CFH on emergency department arrival (median, 25 μM). Patients with these highest CFH levels had longer hospital stays and more frequent complications.

Conclusion: Cell-free hemoglobin is elevated in trauma patients very early after injury and may impact outcome. While further work is needed, early correction of hemolysis could provide benefit.

Level of evidence: Prognostic Study; Level III.