Faculty Bibliography

INTRODUCTION/BACKGROUND:Stop the Bleed (STB) is a national training program aiming to decrease the mortality associated with life-threatening bleeding due to injury. The purpose of this study was to evaluate the efficacy and confidence level of security personnel placing a tourniquet (TQ) compared to civilians. METHODS:Pre and post questionnaires were shared with security personnel (Group 1) and civilians (Group 2). Both groups were assessed to determine comfort level with TQ placement. Time and success rate for placement was recorded pre- and post-STB training. A generalized linear mixed model or generalized estimating equations was used to compare pre and post measurements. RESULTS:There were 234 subjects enrolled. There was a statistically significant improvement between the pre- and post-training responses in both groups with respect to comfort level in placing a TQ. Participants also demonstrated increased familiarity with the anatomy and bleeding control after STB training. A higher successful TQ placement was obtained in both groups after STB training (Pre-training: Group 1 [17.4%], Group 2 [12.8%]; Post-training: Group 1 [94.8%], Group 2 [92.3%]). Both groups demonstrated improved time to TA placement with a longer mean time improvement achieved in Group 1. Although the time to TQ placement pre-and post-training was statistically significant, we found that the post-training times between Groups 1 and 2 were similar (P = .983). CONCLUSIONS:Participants improved their confidence level with the use of hemorrhage control techniques and dramatically increased the rate and time to successful placement of a TQ. While civilians had the greatest increase in comfort level, the security personnel group saw the most significant reduction in the time to successful TQ placement. These findings highlight the critical role of STB in educating and empowering both civilians and security personnel in bleeding control techniques.

BACKGROUND:We hypothesized that the outcomes of trauma patients with a body mass index (BMI) equal to or greater than 30 compared to patients with BMI less than 30 would not differ at a level 1 trauma center that is also a Metabolic and Bariatric Surgery Center of Excellence in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP). STUDY DESIGN/METHODS:Patients equal to and greater than 18 years old treated between 1/1/2018 and 12/31/2020 were included. Demographics, BMI, comorbidities, and outcomes (hospital-LOS, ICU-LOS, blood products used, and mortality) were compared between 2 groups: obese (BMI ≥30) vs non-obese (BMI <30). RESULTS:< .0001). When adjusted for age, sex, DM, dementia, ISS, and ICU admission, there was no statistically significant difference in hospital-LOS (4.30 [95% CI: 4.10, 4.52] vs 4.48 [95% CI: 4.18, 4.79]) or mortality. No statistical differences were seen between the 2 groups in blood product use. CONCLUSIONS:Obesity did not correlate with poorer outcomes at an ACS-verified level 1 Trauma Center and Bariatric Surgery Center of Excellence. Further studies are needed to determine whether outcomes vary at hospitals without both designations.

BACKGROUND:Data access through smartphone applications (apps) has reframed procedure and policy in healthcare, but its impact in trauma remains unclear. Citizen is a free app that provides real-time alerts curated from 911 dispatch data. Our primary objective was to determine whether app alerts occurred earlier than recorded times for trauma team activation and emergency department arrival. METHODS:Trauma registry entries were extracted from a level one urban trauma center from January 1, 2018 to June 30, 2019 and compared with app metadata from the center catchment area. We matched entries to metadata according to description, date, time, and location then compared metadata timestamps to trauma team activation and emergency department arrival times. We computed percentage of time the app reported traumatic events earlier than trauma team activation or emergency department arrival along with exact binomial 95% confidence interval; median differences between times were presented along with interquartile ranges. RESULTS:Of 3,684 trauma registry entries, 209 (5.7%) matched app metadata. App alerts were earlier for 96.1% and 96.2% of trauma team activation and emergency department arrival times, respectively, with events reported median 36 (24-53, IQR) minutes earlier than trauma team activation and 32 (25-42, IQR) minutes earlier than emergency department arrival. Registry entries for younger males, motor vehicle-related injuries and penetrating traumas were more likely to match alerts (P < .0001). CONCLUSION/CONCLUSIONS:Apps like Citizen may provide earlier notification of traumatic events and therefore earlier mobilization of trauma service resources. Earlier notification may translate into improved patient outcomes. Additional studies into the benefit of apps for trauma care are warranted.

PURPOSE: Conclusive data on safety of remdesivir in renal impaired as well as the incidence of liver injury are lacking. The primary objective of this study is to assess the incidence of acute kidney injury (AKI) and to trend the liver function tests (LFTs) during remdesivir treatment and change in eGFR from baseline to end of remdesivir treatment as well as 48 hours after completion of therapy.
METHOD(S): This is a retrospective chart review study including adult Covid19 patients receiving remdesivir with a baseline eGFR< 30 ml/min per 1.73 m^2 from December 2020 to May 2021. The primary outcome of the study is the incidence of AKI and hepatic injury. The secondary outcome is to assess the efficacy of remdesivir defined by oxygen requirement during therapy.
RESULT(S): Seventy-one patients were included in the study. Average eGFR improved by 30.3% at the immediate end of remdesivir treatment and by 30.6% at 48 hours after the end of the treatment (both P< 0.0001). Comparing to baseline, creatinine at the end of remdesivir treatment decreased by 20.9% (P< 0.0001), creatinine of 48 hour after remdesivir treatment decreased by 20.5% (P< 0.0001). Creatinine clearance increased by 26.6% (P< 0.0001) at end of treatment and increased by 26.2% (P< 0.0001) by 48 hours after end of treatment. AST average increased by 2.5% at the end of remdesivir treatment (P=0.727). At 48 hours after remdesivir completion, average AST dropped by 15.8% (P=0.021). ALT average increased by 25% (P=0.004) at the end of remdesivir treatment and increased by 12.0% (P=0.137) at 48 hours after remdesivir completion. Both direct and total bilirubin at end of remdesivir treatment as well as 48 hours later remained stable and did not have significant changes from baseline (P >0.05). Overall, 38% (27 out of 71 patients) experienced oxygenation improvement shown by down-titration of oxygen therapy. Fifty-seven percent of patients received other nephrotoxic medications. The mortality rate is 33.8%. Fifteen of the 71 patients were admitted into ICU. Sixty-five percent (46/71) patients were discharged alive from hospital.
CONCLUSION(S): This study showed that remdesivir use in renally impaired Covid 19 patients with eGFR< 30 ml/min is safe and effective. However, large and prospective studies are needed to validate our findings

PURPOSE/OBJECTIVE:Safety of remdesivir in patients with renal impairment is unknown. Incidence of liver injury secondary to remdesivir is also unknown. The objective of this study is to assess the incidence of acute kidney injury (AKI) and to trend the liver enzymes during remdesivir treatment and change in eGFR from baseline to end of treatment as well as 48 h post completion of remdesivir therapy. METHODS:This is a retrospective chart review study including adult patients admitted with COVID-19 receiving remdesivir with a baseline eGFR < 30 ml/min per 1.73 m^2 from December 2020 to May 2021. The primary outcome was to assess the incidence of AKI and hepatic injury. The secondary outcome was to assess the efficacy of remdesivir defined by change in oxygen requirement. RESULTS:Seventy-one patients were included in the study. Patients experienced an improvement in eGFR from baseline (T0) to end of remdesivir treatment (T1), as well as 48 h after the end of the treatment (T2) ( + 30.3% and + 30.6% respectively, P < .0001). Creatinine reduced from baseline (T0) to T1 and T2 (-20.9% and -20.5% respectively, P < .0001). Creatinine clearance improved from baseline to T1 and T2 ( + 26.6% and + 26.2% respectively, p < .0001). Elevation of aminotransferase (AST) was observed at T1 ( + 2.5%, P  =  .727), however, AST reduction was seen at T2 (-15.8%, P  =  .021). Elevation in alanine transaminase (ALT) was observed at T1 and T2 ( + 25% and + 12%, P  =  .004 and P  =  .137 respectively). Both direct and total bilirubin remained stable and were not significantly changed from baseline. CONCLUSION/CONCLUSIONS:Our study showed that remdesivir use in renally-impaired patients with eGFR < 30 ml/min is safe. Remdesivir may be considered as a therapeutic option in this population with COVID-19 infection.

Introduction: Stop the Bleed (STB) is a national training program aiming to decrease the mortality associated with life-threatening bleeding due to injury. The purpose of this study was to evaluate the efficacy and confidence level of security personnel placing a tourniquet (TQ) compared to civilians.
Method(s): Pre and post questionnaires were shared with security personnel (Group 1), and civilians (Group 2). Both groups were assessed to determine comfort level with TQ placement. Time and success rate for placement was recorded pre- and post-STB training. A generalized linear mixed model or generalized estimating equations were used.
Result(s): 234 subjects were enrolled. There was a statistically significant improvement between the pre- and post-training responses in both groups with respect to comfort level in TQ placing. Participants also demonstrated increased familiarity with the anatomy and bleeding control after being trained. A higher successful tourniquet placement was obtained in both groups after training (Pre-training: Group-1[17.4%], Group-2[12.8%], Post-training: Group-1[94.8%], Group-2[92.3%]). Both groups demonstrated improved time to placement with a longer mean time improvement achieved in Group 1. Although the time to TQ placement pre-and post-training was statistically significant, we found that the post-training times between groups 1 and 2 were similar (p=0.983).
Conclusion(s): Participants improved their confidence level and dramatically increased the rate and time to successful TQ placement. While civilians had the greatest increase in comfort level, the security personnel group saw the most significant reduction in the time to successful placement. These findings highlight the critical role of STB in bleeding control techniques.
Copyright

A high number of fatalities can occur during major disasters or during events like the COVID-19 pandemic. In a natural disaster, the dead must be removed from disaster sites while rescue work is in progress; otherwise, the health and safety of the community are threatened. The COVID-19 pandemic is analogous to a natural disaster with mass casualties where the disaster sites are hospitals with morgues that are overwhelmed. As the number of the deceased rise rapidly and hospital morgues are at their full capacity, hospitals use what is called a Body Collection Point (BCP). BCP is defined as a temporary refrigeration unit used to store decedents until transport is arranged. Decedents should always be handled in a manner denoting respect, and provisions and management of resources should be properly mobilized to ensure this. Contingency plans must be created to prepare for worsening of the disaster that further overwhelms the capacity of the health care systems.

Introduction: With an aging population, management of biologic therapy in IBD patients with active or recent cancer is challenging. We evaluated the comparative safety of non-tumor necrosis factor (TNF)-a directed therapy vs. TNFa antagonists vs. immunomodulator monotherapy (IMM) in IBD patients with active or recent cancer (<=5 years).
Method(s): Through the collaborative REACH-IBD (Rising Educators Academics and Clinicians Helping IBD) research initiative, we conducted a retrospective, multi-center cohort study. We included IBD patients from 12 centers with active cancer (Cohort A) or recent cancer within = years (Cohort B) who were treated with non-TNFa biologics vs. TNFa antagonists (reference) after cancer diagnosis.We excluded patients with nonmelanoma skin cancer. Primary outcomes were cancer progression (Cohort A) or new/recurrent cancer (Cohort B). We performed Cox proportional hazard analysis to compare the safety of different biologics.
Result(s): (Cohort A)We included 107 patients with active cancer (5416y, 62% male, 72% solid cancer, 400 person-year follow-up), of whom 35 were treated with non-TNFa biologics (29 vedolizumab, 6 ustekinumab), 45 with TNFa antagonists and 27 with IMM (Table 1). Overall, 19 patients had progression of cancer, 13 died and 20 were hospitalized for serious infection (Figure 1A). After adjusting for age and type of active cancer, there was no difference in the risk of cancer progression (non-TNFa biologics vs. TNFa antagonists: HR, 1.55; 95% CI, 0.48-5.03), mortality (HR, 2.74; 95% CI, 0.25-30.5) and serious infections (HR, 1.90; 95% CI, 0.15-24.0) between patients treated with non-TNFa biologics vs. TNFa antagonists. (Cohort B) We included 141 patients with recent prior cancer (5214y, 51% male, 86% solid cancer; duration of remission prior to starting biologics, 1719m) of whom 54 were treated with non-TNFa biologics (40 vedolizumab, 14 ustekinumab), 63 with TNFa antagonists and 24 with IMM (Table 1). Overall, 14 patients had recurrence of cancer (or developed new incident cancer) and 6 died (Figure 1B). After adjusting for age, type of prior cancer and duration of remission, there was no difference in the risk of cancer recurrence between non-TNFa biologics vs. TNFa antagonists (HR, 0.97; 95% CI, 0.16-5.75).
Conclusion(s): In IBD patients with active or recent cancer (within = years), non-TNFa-directed biologics and TNFa antagonists have comparable safety. Choice of biologic should be dictated by IBD disease severity, in collaboration with an oncologist

Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position. The improvement of oxygenation during prone ventilation is multifactorial, but occurs mainly by reducing lung compression and improving lung perfusion. CT imaging modeling data demonstrated that the asymmetry of lung shape leads to a greater induced pleural pressure gravity gradient when supine as compared to prone positioning. Although proning is indicated in patients with severe ARDS who are not responding to other ventilator modalities, this technique has moved away from a salvage therapy for refractory hypoxemia to an upfront lung-protective strategy intended to improve survival in severe ARDS, especially due to the current COVID-19 pandemic. In view of different roles, we surgeons had to take during the COVID-19 pandemic, it is of importance to learn how to implement this therapeutic measure, especially in a surgical critical care unit setting. As such, this article aims to review the physiological principles and effects of the prone ventilation, positioning, as well as its contraindications and complications.

INTRODUCTION/BACKGROUND:Stop the Bleed (STB) program was launched by the White House, for the use of bleeding control techniques at the scene of traumatic injury. The purpose of this study was to conduct an STB course in private security and law enforcement personnel. METHODS:Pre- and post-questionnaire using the Likert scale was shared with participants on their knowledge and comfort level with the use of tourniquets. Participants were also observed while placing tourniquets and the time for placement recorded. The didactic portion and practical session of the STB was then taught and participants were again observed placing tourniquets and a questionnaire distributed. Fisher's exact tests or Wilcoxon matched-pairs signed-ranks tests were used to compare pre-post measurements. RESULTS:A total of 151 subjects were enrolled over the course of seven sessions. The tourniquet was applied correctly by 17.2% (26/151) and 92.7% (140/151) at the pre- and post-instruction assessments, respectively (p < 0.001). Mean times to apply the tourniquet were 29.8 ± 18.5 and 18.7 ± 6.7 s, respectively (p < 0.001). Subjects reported their level of comfort with the tourniquet to be 5.1 ± 3.3 and 8.8 ± 2.2, respectively (p < 0.001), and their familiarity with anatomy and bleeding control to be 5.2 ± 3.1 and 8.2 ± 2.4, respectively (p < 0.001). At the end of the course, the mean score in response to a question about the extent to which the explanation had helped was 9.0 ± 1.9 (95% CI 8.7-9.4) and to a question about the extent to which teaching would make them feel more secure and safe was 9.2 ± 1.9 (95% CI 8.9-9.5). CONCLUSIONS:STB course improved correct tourniquet placement, demonstrated dramatic improvements in application time, and increased levels of comfort. These findings validate the need for ongoing teaching and education.