bluuebunny/crossref_metadata_2025_split huggingface dataset:
Outcomes of Surgical vs Non-Surgical Treatment for Multiple Rib Fractures: A US Hospital Matched Cohort Database Analysis
Authors: Shiroff Adam M. , Wolf Simone , Wu Alex , Vanderkarr Mollie , Anandan Manoranjith , Ruppenkamp Jill W. , Galvain Thibaut , Holy Chantal E. 
Published: February 2023

Abstract

Background
Treatment for multiple rib fractures (MRF) includes surgical stabilization of rib fractures (SSRF) or non-operative management (NOM). Meta-analyses have demonstrated that SSRF results in faster recovery and lower long-term complication rates vs NOM. Our study evaluated post-operative outcomes for MRF patients following SSRF vs NOM in a real world, all-comer study design.

Methods
MRF Patients with inpatient admissions in the PREMIER hospital database from 10/01/2015 to 09/30/2020 were identified. Outcomes included discharge disposition and 3- and 12-month lung-related readmissions. Demographics, comorbidities, concurrent injuries at index, abbreviated injury scale and injury severity scores, and provider characteristics, were determined for all patients. Patients were excluded from the cohort if they had a thorax AIS < 2 (low severity patient) or a Glasgow coma score ≤ 8 (extreme high severity patient). Stratum matching between SSRF and NOM patients was performed using fine stratification and weighting, so that all patient data was kept in the final analysis. Outcomes were analyzed using generalized linear models with quasinormal distribution and logit links.

Results
203,450 patients were included, of which 200,580 NOM and 2,870 SSRF. SSRF patients had higher rates of home discharge (62% SSRF vs 58% NOM), and lower rates of lung-related readmissions (3 months: 3.1% SSRF vs 4.0% NOM; 12 months: 6.2% SSRF vs 7.6% NOM). The odds ratio (OR) for home or home health discharge in patients with SSRF vs NOM was 1.166 (95% confidence interval (CI): 1.073-1.266, p = 0.0002). Similarly, odd ratios for lung-related readmission at 3- and 12-month were statistically lower in the patients treated with SSRF vs NOM (OR (3 month): 0.764 (95%CI: 0.606-0.963), p = 0.0227 and OR (12 months): 0.799 (95%CI: 0.657-0.971), p = 0.0245).

Conclusion
SSRF results in greater odds of home discharge and lower rates of lung-related readmissions compared to NOM at 12 months follow-up.

Level of Evidence
III
Detection of pneumothorax on ultrasound using artificial intelligence
Authors: Montgomery Sean , Li Forrest , Funk Christopher , Peethumangsin Erica , Morris Michael , Anderson Jess T. , Hersh Andrew M. , Aylward Stephen 
Published: February 2023

BACKGROUND
Ultrasound (US) for the detection of pneumothorax shows excellent sensitivity in the hands of skilled providers. Artificial intelligence may facilitate the movement of US for pneumothorax into the prehospital setting. The large amount of training data required for conventional neural network methodologies has limited their use in US so far.

METHODS
A limited training database was supplied by Defense Advanced Research Projects Agency of 30 patients, 15 cases with pneumothorax and 15 cases without. There were two US videos per patient, of which we were allowed to choose one to train on, so that a limited set of 30 videos were used. Images were annotated for ribs and pleural interface. The software performed anatomic reconstruction to identify the region of interest bounding the pleura. Three neural networks were created to analyze images on a pixel-by-pixel fashion with direct voting determining the outcome. Independent verification and validation was performed on a data set gathered by the Department of Defense.

RESULTS
Anatomic reconstruction with the identification of ribs and pleura was able to be accomplished on all images. On independent verification and validation against the Department of Defense testing data, our program concurred with the SME 80% of the time and achieved a 86% sensitivity (18/21) for pneumothorax and a 75% specificity for the absence of pneumothorax (18/24). Some of the mistakes by our artificial intelligence can be explained by chest wall motion, hepatization of the underlying lung, or being equivocal cases.

CONCLUSION
Using learning with limited labeling techniques, pneumothorax was identified on US with an accuracy of 80%. Several potential improvements are controlling for chest wall motion and the use of longer videos.

LEVEL OF EVIDENCE
Diagnostic Tests; Level III.
Variation in tracheostomy placement and outcomes following pediatric trauma among adult, pediatric, and combined trauma centers
Authors: Killien Elizabeth Y. , Grassia Kalee L. , Butler Elissa K. , Mooney Stephen J. , Watson R. Scott , Vavilala Monica S. , Rivara Frederick P. 
Published: February 2023

BACKGROUND
Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults.

METHODS
We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care.

RESULTS
Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20–1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48–2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7–88.1%) at combined centers and 85.3% higher (56.6–113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (−4.4 days, −7.4 to −1.3 days) or adult (−4.0 days, −7.2 to −0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03–4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31–4.83]).

CONCLUSION
Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system.

LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level III.
Implementation science approaches to optimizing venous thromboembolism prevention in patients with traumatic injuries: Findings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma
Authors: Ratnasekera Asanthi , Geerts William , Haut Elliott R. , Price Michelle , Costantini Todd , Murphy Patrick 
Published: February 2023

ABSTRACT
Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate that VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial, and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated because they apply to trauma patients. Nonadministration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.
Multiyear experience with mobile online platform for documentation of acute care surgery fellows supervision
Authors: Gunter Oliver L. , Devasahayam Rebekah J. , Dennis Bradley M. , Gondek Stephen P. , Adams Raeanna C. , Guillamondegui Oscar D. 
Published: February 2023

BACKGROUND
There is currently no standard for documenting supervision of acute care surgery (ACS) fellows. To accomplish this goal, we developed a web-based survey that is accessible via mobile platform. We hypothesize that our mobile access survey is an effective, reproducible tool for assessing fellow clinical performance.

METHODS
A retrospective review from 2016 to 2022 of all data captured in an encrypted database on all ACS fellows at our institution was performed. Supervision was defined as: Type 1 direct face-to-face, Type 2a immediately available in-house, Type 2b available after notification via phone with remote electronic medical record access, and Type 3 retrospective review. Data were collected by supervising faculty using a web-based clinical performance survey created by fellowship program leadership. Survey data collected included clinical summary, trainee, proctoring faculty, clinical service, operative/nonoperative, supervision type, Zwisch autonomy scale, time to input data, and graduate medical education milestone performance. Data were analyzed using descriptive statistics.

RESULTS
A total of 883 proctoring events were identified, including the majority as Type 1 (97.4%). Trauma comprised 64% of evaluations. Fifty-two percent of the proctoring events were surgical cases. Complexity was graded as average (77%), hardest (16%), basic (7%). Guidance included supervision only, 491 of 666 (74%), with 26% requiring faculty intervention. Fellow performance was graded as average (66%), above average (31%), and below average/critical deficiency (3%). Graduate medical education performance was available for 247 of 883 interactions identifying 31 events with potential for improvement. Average evaluation completion time: 2 minutes (n = 134).

CONCLUSION
A mobile web-based survey is a convenient and reliable tool for documenting ACS fellow clinical activity and was effectively used by all ACS faculty to record supervision. A combination of clinical and objective data is useful to determine ACS fellows' performance and to provide targeted education and remediation.

LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level IV.
Is perioperative COVID-19 really associated with worse surgical outcomes? A nationwide COVIDSurg propensity-matched analysis
Authors: Argandykov Dias , Dorken-Gallastegi Ander , El Moheb Mohamad , Gebran Anthony , Proaño-Zamudio Jefferson A. , Bokenkamp Mary , Renne Angela M. , Nepogodiev Dmitri , Bhangu Aneel , Kaafarani Haytham M.A. ,   on behalf of the COVIDSurg Collaborative
Published: February 2023

BACKGROUND
Patients undergoing surgery with perioperative COVID-19 are suggested to have worse outcomes, but whether this is COVID-related or due to selection bias remains unclear. We aimed to compare the postoperative outcomes of patients with and without perioperative COVID-19.

METHODS
Patients with perioperative COVID-19 diagnosed within 7 days before or 30 days after surgery between February and July 2020 from 68 US hospitals in COVIDSurg, an international multicenter database, were 1:1 propensity score matched to patients without COVID-19 undergoing similar procedures in the 2012 American College of Surgeons National Surgical Quality Improvement Program database. The matching criteria included demographics (e.g., age, sex), comorbidities (e.g., diabetes, chronic obstructive pulmonary disease, chronic kidney disease), and operation characteristics (e.g., type, urgency, complexity). The primary outcome was 30-day hospital mortality. Secondary outcomes included hospital length of stay and 13 postoperative complications (e.g., pneumonia, renal failure, surgical site infection).

RESULTS
A total of 97,936 patients were included, 1,054 with and 96,882 without COVID-19. Prematching, COVID-19 patients more often underwent emergency surgery (76.1% vs. 10.3%, p < 0.001). A total of 843 COVID-19 and 843 non–COVID-19 patients were successfully matched based on demographics, comorbidities, and operative characteristics. Postmatching, COVID-19 patients had a higher mortality (12.0% vs. 8.1%, p = 0.007), longer length of stay (6 [2–15] vs. 5 [1–12] days), and higher rates of acute renal failure (19.3% vs. 3.0%, p < 0.001), sepsis (13.5% vs. 9.0%, p = 0.003), and septic shock (11.8% vs. 6.0%, p < 0.001). They also had higher rates of thromboembolic complications such as deep vein thrombosis (4.4% vs. 1.5%, p < 0.001) and pulmonary embolism (2.5% vs. 0.4%, p < 0.001) but lower rates of bleeding (11.6% vs. 26.1%, p < 0.001).

CONCLUSION
Patients undergoing surgery with perioperative COVID-19 have higher rates of 30-day mortality and postoperative complications, especially thromboembolic, compared with similar patients without COVID-19 undergoing similar surgeries. Such information is crucial for the complex surgical decision making and counseling of these patients.

LEVEL OF EVIDENCE
Prognostic and Epidemiologic; Level IV.
The Utah Pediatric Trauma Network, a statewide pediatric trauma collaborative can safely help nonpediatric hospitals admit children with mild traumatic brain injury
Authors: Fenton Stephen J. , Swendiman Robert A. , Eyre Matthew , Larsen Kezlyn , Russell Katie W. 
Published: February 2023

BACKGROUND
Created in 2019, the Utah Pediatric Trauma Network (UPTN) is a transparent noncompetitive collaboration of all hospitals in Utah with the purpose of improving pediatric trauma care. The UPTN implements evidence-based guidelines based on hospital resources and capabilities with quarterly review of data collected in a network-specific database. The first initiative was to help triage the care of traumatic brain injury (TBI) to prevent unnecessary transfers while ensuring appropriate care. The purpose of this study was to review the effectiveness of this network wide guideline.

METHODS
The UPTN REDCap database was retrospectively reviewed between January 2019 and December 2021. Comparisons were made between the pediatric trauma center (PED1) and nonpediatric hospitals (non-PED1) in admissions of children with very mild, mild, or complicated mild TBI.

RESULTS
Of the total 3,315 cases reviewed, 294 were admitted to a non-PED1 hospital and 1,061 to the PED1 hospital with very mild/mild/complicated mild TBI. Overall, kids treated at non-PED1 were older (mean, 14.9 vs. 7.7 years; p = 0.00001) and more likely to be 14 years or older (37% vs. 24%, p < 0.00001) compared with those at PED1. Increased admissions occurred post-UPTN at non-PED1 hospitals compared with pre-UPTN (43% vs. 14%, p < 0.00001). Children admitted to non-PED1 hospitals post-UPTN were younger (9.1 vs. 15.7 years, p = 0.002) with more kids younger than 14 years (67% vs. 38%, p = 0.014) compared with pre-UPTN. Two kids required next-day transfer to a higher-level center (1 to PED1), and none required surgery or neurosurgical evaluation. The mean length of stay was 21.8 hours (interquartile range, 11.9–25.4). Concomitantly, less children with very mild TBI were admitted to PED1 post-UPTN (6% vs. 27%, p < 0.00001) and more with complicated mild TBI (63% vs. 50%, p = 0.00003) than 2019.

CONCLUSION
Implementation of TBI guidelines across the UPTN successfully allowed nonpediatric hospitals to safely admit children with very mild, mild, or complicated mild TBI. In addition, admitted kids were more like those treated at the PED1 hospital.

LEVEL OF EVIDENCE
Prognostic/Epidemiological; Level IV.
Is the use of nonsteroidal anti-inflammatories after bowel anastomosis in trauma safe?
Authors: Clements Thomas W. , Van Gent Jan-Michael , Hatton Gabrielle E. , Estrada Michelle , Agarwal Amit K. , Cotton Bryan A. 
Published: February 2023

BACKGROUND
With an increasing interest in multimodal and opioid-reducing pain strategies, nonsteroidal anti-inflammatory drugs (NSAIDs) have become common place in the care of injured patients. Long-standing concerns of increased anastomotic leak (AL) rate with the use of NSAIDs, however, have persisted. We hypothesized that there would be no significant risk associated with NSAID use after bowel anastomosis in trauma patients.

METHODS
All patients presenting to a level 1 trauma center who required intestinal resection and anastomosis from 2011 to 2017 were reviewed. Patients receiving NSAIDs were compared with those managed without NSAIDs. Primary outcome of interest was anastomosis-related complications (AL, intra-abdominal abscess, anastomotic bleed, fascial dehiscence, fascial dehiscence, and enterocutaneous fistula). Multivariable logistic regression analyses were performed with propensity adjustment for inverse probability of NSAID treatment weights.

RESULTS
A total of 295 patients met the inclusion criteria with 192 receiving NSAIDs. Patients receiving NSAIDs had lower abdominal Abbreviated Injury Scale and Injury Severity Score (p < 0.046). Arrival systolic blood pressure, diastolic blood pressure, and Glasgow Coma Scale were higher in the NSAID group (p < 0.013). After propensity weighting, NSAID use was not a major predictor of anastomotic complication (p = 0.39). There was an increased risk of AL with perioperative vasopressor exposure (odds ratio [OR], 3.33; 95% confidence interval [CI], 1.17–9.05; p < 0.001). Increasing red blood cell transfusions in the first 24 hours were associated with intra-abdominal complications (OR, 1.02; 95% CI, 1.00–1.04; p = 0.05). Nonsteroidal anti-inflammatory drug exposure demonstrated a weak association with AL (OR, 1.92; 95% CI, 0.97–3.90; p = 0.06).

CONCLUSION
Consistent with previous studies, perioperative vasopressor exposure and increased number of red blood cell transfusions are risk factors for ALs and intra-abdominal complications, respectively. Nonsteroidal anti-inflammatory drug use in trauma patients with multiple risk factors may be associated with an increased risk of AL and should be used with caution in the setting of other established risk factors.

LEVEL OF EVIDENCE
Therapeutic/Care Management; Level III.
Association of race and socioeconomic status with time to pain control among pediatric trauma patients managed nonoperatively
Authors: Trinidad Stephen , Jenkins Todd , Falcone Kelly , Denning Jaime Rice , Chidambaran Vidya , Kotagal Meera 
Published: February 2023

BACKGROUND
Few studies have evaluated racial/ethnic inequities in acute pain control among hospitalized injured children. We hypothesized that there would be inequities in time to pain control based on race/ethnicity and socioeconomic status.

METHODS
We performed a retrospective cohort study of all injured children (7–18 years) admitted to our level 1 trauma center between 2010 and 2019 with initial recorded numerical rating scale (NRS) scores of >3 who were managed nonoperatively. A Cox regression survival analysis was used to evaluate the time to pain control, defined as achieving an NRS score of ≤3.

RESULTS
Our cohort included 1,787 admissions. The median age was 14 years (interquartile range, 10–18), 59.5% were male, 76.6% identified as White, 19.9% as Black, and 2.4% as Hispanic. The median initial NRS score was 7 (interquartile range, 5–9), and the median time to pain control was 4.9 hours (95% confidence interval, 4.6–5.3). Insurance status, as a marker of socioeconomic status, was not associated with time to pain control (p = 0.29). However, the interaction of race/ethnicity and deprivation index was significant (p = 0.002). Specifically, the socioeconomic deprivation of a child's home neighborhood was an important predictor for non-White children (p <0.003) but not for White children (p = 0.41) and non-White children from higher deprivation neighborhoods experienced greater times to pain control (hazard ratio, 1.55; 95% confidence interval, 1.16–2.07). Being female, older, presenting with higher initial NRS scores, and having history of attention-deficit/hyperactivity disorder were all associated with longer times to pain control. Other injury characteristics and psychiatric history were evaluated but ultimately excluded, as they were not significant.

CONCLUSION
Greater neighborhood socioeconomic deprivation was associated with prolonged time to pain control for non-White children admitted after injury and managed nonoperatively. Further work is needed to understand inequities in pain control for injured patients.

LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level IV.
Evaluating associations between level of trauma care and outcomes of patients with specific severe injuries: A systematic review and meta-analysis
Authors: Van Ditshuizen Jan C. , Rojer Leonne A. , Van Lieshout Esther M.M. , Bramer Wichor M. , Verhofstad Michiel H.J. , Sewalt Charlie A. , Den Hartog Dennis 
Published: February 2023

BACKGROUND
Trauma networks have multiple designated levels of trauma care. This classification parallels concentration of major trauma care, creating innovations and improving outcome measures.

OBJECTIVES
The objective of this study is to assess associations of level of trauma care with patient outcomes for populations with specific severe injuries.

METHODS
A systematic literature search was conducted using six electronic databases up to April 19, 2022 (PROSPERO CRD42022327576). Studies comparing fatal, nonfatal clinical, or functional outcomes across different levels of trauma care for trauma populations with specific severe injuries or injured body region (Abbreviated Injury Scale score ≥3) were included. Two independent reviewers included studies, extracted data, and assessed quality. Unadjusted and adjusted pooled effect sizes were calculated with random-effects meta-analysis comparing Level I and Level II trauma centers.

RESULTS
Thirty-five studies (1,100,888 patients) were included, of which 25 studies (n = 443,095) used for meta-analysis, suggesting a survival benefit for the severely injured admitted to a Level I trauma center compared with a Level II trauma center (adjusted odds ratio [OR], 1.15; 95% confidence interval [CI], 1.06–1.25). Adjusted subgroup analysis on in-hospital mortality was done for patients with traumatic brain injuries (OR, 1.23; 95% CI, 1.01–1.50) and hemodynamically unstable patients (OR, 1.09; 95% CI, 0.98–1.22). Hospital and intensive care unit length of stay resulted in an unadjusted mean difference of −1.63 (95% CI, −2.89 to −0.36) and −0.21 (95% CI, −1.04 to 0.61), respectively, discharged home resulted in an unadjusted OR of 0.92 (95% CI, 0.78–1.09).

CONCLUSION
Severely injured patients admitted to a Level I trauma center have a survival benefit. Nonfatal outcomes were indicative for a longer stay, more intensive care, and more frequently posthospital recovery trajectories after being admitted to top levels of trauma care. Trauma networks with designated levels of trauma care are beneficial to the multidisciplinary character of trauma care.

LEVEL OF EVIDENCE
Systematic review and meta-analysis; Level III.