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Background Non-elective cholecystectomies can lead to severe postoperative complications and mortality. Existing risk prediction tools do not meet the need to reliably predict these complications. Methods Using the 2011–2016 American College of Surgeons National Surgical Quality Improvement Program datasets, we identified patients undergoing non-elective cholecystectomy with primary ICD 9/10 codes indicating the following diagnoses: symptomatic cholelithiasis, acute cholecystitis, choledocholithiasis, gallstone pancreatitis, and cholangitis. We randomly allocated patients to derivation and validation cohorts (80/20 split). Severe complications (Clavien-Dindo grades IV and V) included unplanned intubation, prolonged mechanical ventilation, pulmonary embolism, acute renal failure requiring dialysis, stroke, myocardial infarction, cardiac arrest, septic shock, and mortality. Logistic regression using backward selection identified predictors of severe complications and a risk score was generated based on this model. Results Of 68,953 patients in the derivation cohort, 1.7% ( N  = 1157) suffered severe complications. The final multivariable risk score model included the following predictors: age (0–12 points), preoperative sepsis (5 points), planned open procedure (5 points), estimated glomerular filtration rate (0–13 points), and preoperative albumin level (0–8 points). The associated risk-score model yielded scores from 0 to 43 with 0.1–59.4% predicted probability of severe complications and had a C-statistic of 0.845 (95% CI 0.834, 0.857) in the derivation cohort and 0.870 (95% CI 0.851, 0.889) in the validation cohort. Conclusion A simple risk-score model predicts severe complications in patients undergoing unplanned cholecystectomy for common indications encountered in an acute care surgery service and identifies high-risk patients.

IntroductionRepeated pediatric assault should be a never event. The purpose of this study was to evaluate the readmission and reinjury patterns in pediatric victims of assault including readmissions to different hospitals across the US.MethodsThe 2010–2014 Nationwide Readmissions Database was queried for all nonelective admissions for patients under the age of 18 years. Primary outcomes were readmission or reinjury within 1 year. Results were weighted for national estimates.ResultsAssault-related injury occurred in 46,294 pediatric patients with 11.4% of patients being readmitted within 1 year. Of those readmitted, 35.2% presented to a different hospital. Reinjury within 1 year occurred in about 1% of patients, with 14.8% of those presenting to a different hospital. Age < 13 years, firearm-injury, ISS > 15, female gender, and leaving AMA were found to be independent prognostic indicators of readmission within 1 year among pediatric assault patients.ConclusionCare of children who are admitted and discharged for assault injuries is more fragmented that previously thought. Quality metrics fail to capture this previously hidden population. Our results identify treatable factors which could improve the care of children after assault.

Percutaneous dilational tracheostomy (PDT) is a commonly used technique in intensive care units (ICUs) for persistent respiratory failure. Early complications of placement includeairway loss, bleeding, and tracheal ring fracture. Tracheostomy tube fracture is a rarely reported complication that can lead to loss of airway and require emergent intervention. We present two case reports of tracheostomy flange fracture and dislocation after PDT. Shortly after insertion, the tracheostomy flange was incidentally noted to have irreparably fractured and separated from the outer cannula. Both patients were orotracheally intubated and converted to open revisional surgical tracheostomy. Outer cannula separation from the flange is a rare but important complication of PDT due to the risk of occult airway loss. The tracheostomy tube supplied in the PDT set is manufactured in three parts and the plastic outer cannula is snapped to the silicone flange during manufacturing. The flange is not meant to be separated during insertion or use. PDT insertion requires significant force to be exerted, as the catheter has to travel through the subcutaneous tissue of the neck before entering the trachea. These cases suggest that the junction of the flange and the outer cannula may be a weak point and that fracture and dislocation at that site may occur due to excessive or misdirected force. Dislocation may cause loss of airway and a need for orotracheal intubation as performed in our cases. Understanding this complication and carefully examining the flange after placement is essential for early recognition to avoid loss of airway.

PurposeDirect peritoneal resuscitation (DPR) has been used to help preserve microcirculation by reversing vasoconstriction and hypoperfusion associated with the pathophysiological process of shock, which can occur despite appropriate intravenous resuscitation. This approach depends on infusing a hyperosmolar solution intraperitoneally via a percutaneous catheter with the tip ending near the pelvis or the root of the mesentery. The abdomen is usually left open with a negative pressure abdominal dressing to continuously evacuate the infused dialysate. Hypertonicity of the solution triggers visceral vasodilation to help maintain blood flow, even during shock, and is also associated with reduced local inflammatory cytokines and other mediators, preservation of endothelial cell function, and mitigation of organ edema and necrosis. It also has a direct effect on liver perfusion and edema, more rapidly corrects electrolyte abnormalities compared to intravenous resuscitation alone, and may requireless intravenous fluid to stabilize blood pressure, all of which shortens the time required to close patients’ abdomen.MethodsAn online query using the search term “direct peritoneal resuscitation” was carried out in PubMed, MEDLINE and SciELO, limited to publications indexed from January 2014 to June 2020. Of the 20 articles returned, full text was able to be obtained for 19. A manual review of included articles’ references was resulted in the addition of 1 article, for a total of 20 included articles.ResultsThe 20 articles were comprised of 15 animal studies, 4 clinical studies,and 1 expert opinion. The benefits include both local and possibly systemic effects on perfusion, hypoxia, acidosis, and inflammation, and are associated with improved outcomes and reduced complications.ConclusionDPR shows promise in patients with hemorrhagic shock, septic shock, and other conditions resulting in an open abdomen after damage control laparotomy.

BackgroundIntimate partner violence (IPV) is a serious public health issue with a substantial burden on society. Screening and intervention practices vary widely and there are no standard guidelines. Our objective was to review research on current practices for IPV prevention in emergency departments and trauma centers in the USA and provide evidenced-based recommendations.MethodsAn evidence-based systematic review of the literature was conducted to address screening and intervention for IPV in adult trauma and emergency department patients. The Grading of Recommendations, Assessment, Development and Evaluations methodology was used to determine the quality of evidence. Studies were included if they addressed our prespecified population, intervention, control, and outcomes questions. Case reports, editorials, and abstracts were excluded from review.ResultsSeven studies met inclusion criteria. All seven were centered around screening for IPV; none addressed interventions when abuse was identified. Screening instruments varied across studies. Although it is unclear if one tool is more accurate than others, significantly more victims were identified when screening protocols were implemented compared with non-standardized approaches to identifying IPV victims.ConclusionOverall, there were very limited data addressing the topic of IPV screening and intervention in emergency medical settings, and the quality of the evidence was low. With likely low risk and a significant potential benefit, we conditionally recommend implementation of a screening protocol to identify victims of IPV in adults treated in the emergency department and trauma centers. Although the purpose of screening would ultimately be to provide resources for victims, no studies that assessed distinct interventions met our inclusion criteria. Therefore, we cannot make specific recommendations related to IPV interventions.PROSPERO registration numberCRD42020219517.

The worst cholera epidemic in recent history began in Haiti in October, 2010. By August 2012, more than 7500 people had died and almost 600 000 cases were recorded. Published research and a UN investigation suggest that the UN military mission, MINUSTAH, was the most likely source, caused by failures in medical screening and waste management. The UN has not used these findings to update its policy. We postulate that this was partly because UN officials might be unable to understand the data. Helping UN officials to comprehend the data could enable quick, evidence-based protocol reform. We investigated knowledge and interpretation of scientific reports by UN officials. We searched PubMed for articles published between October 2010, and June 2012, with the terms “Haiti” and “cholera”. Only original research about the origins of cholera in Haiti were included. Of 103 articles found, seven met this inclusion criterion. We also included data from the UN report. We supplemented our PubMed search with discussions with the authors of the identified reports. We provided scientific briefs to UN officials who responded to the cholera epidemic. We met with 23 UN officials, including permanent mission representatives. We asked officials if they saw a need for translation of scientific findings, found briefings helpful in shaping policy, and could foresee briefings influencing policy recommendations. 21 officials expressed difficulty understanding the scientific data and said that they would appreciate help interpreting results. All asked questions about the published research that they felt were not answered by lay media reporting. None had read any original articles, although 20 had read excerpts from or all of the UN report. Every official reported an improved understanding of the origin of cholera in Haiti after a briefing. 16 officials thought that our briefings could help shape policy. All officials felt that regular communication between scientists and policy makers was essential to inform policy changes. 21 officials stated that they had not been previously approached by the scientific community to assist them with interpretation of the data to help guide policy reform. A comprehensive response to and prevention of epidemics requires collaboration between researchers and policy makers. In the Haiti cholera epidemic, the scientific community and UN officials were addressing a common crisis but working independently. Partnership between science and policy needs proactive, independent researchers who seek out policy makers and help them to interpret scientific data. Almost 2 years into the cholera epidemic, the UN has not updated any of its medical or waste policies. If more people can help UN officials to understand scientific findings, the UN might speed up updating its protocols, which could save the lives of UN staff and the people they serve. None.

Adrenal - renal fusion is a rare entity defined as incomplete encapsulation of the adrenal gland and kidney with histologically adjacent functional tissue. This report describes the first published intraoperative identification of this anomaly during laparoscopic adrenalectomy. The patient was a 59-year-old man with chronic hypertension refractory to multiple antihypertensives found to be caused by a right-sided aldosterone-producing adrenal adenoma in the setting of bilateral adrenal hyperplasia. During laparoscopic adrenalectomy, the normal avascular plane between the kidney and adrenal gland was absent. Pathologic evaluation confirmed adrenal - renal fusion without adrenal heterotopia. Identified intraoperatively, this may be misdiagnosed as invasive malignancy, and thus awareness of this anomaly may help prevent unnecessarily morbid resection.

The purpose of this study was to use natural language processing of physician documentation to predict mortality in patients admitted to the surgical intensive care unit (SICU). The Multiparameter Intelligent Monitoring in Intensive Care III database was used to obtain SICU stays with six different severity of illness scores. Natural language processing was performed on the physician notes. Classifiers for predicting mortality were created. One classifier used only the physician notes, one used only the severity of illness scores, and one used the physician notes with severity of injury scores. There were 3838 SICU stays identified during the study period and 5.4 per cent ended with mortality. The classifier trained with physician notes with severity of injury scores performed with the highest area under the curve (0.88 ± 0.05) and accuracy (94.6 ± 1.1%). The most important variable was the Oxford Acute Severity of Illness Score (16.0%). The most important terms were “dilated” (4.3%) and “hemorrhage” (3.7%). This study demonstrates the novel use of artificial intelligence to process physician documentation to predict mortality in the SICU. The classifiers were able to detect the subtle nuances in physician vernacular that predict mortality. These nuances provided improved performance in predicting mortality over physiologic parameters alone.

The purpose of this study was to compare machine learning techniques for predicting central line-associated bloodstream infection (CLABSI). The Multiparameter Intelligent Monitoring in Intensive Care III database was queried for all ICU admissions. The variables included six different severities of illness scores calculated on the first day of ICU admission with their components and comorbidities. The outcomes of interest were in-hospital mortality, central line placement, and CLABSI. Predictive models were created for these outcomes using classifiers with different algorithms: logistic regression, gradient boosted trees, and deep learning. There were 57,786 total hospital admissions and the mortality rate was 10.1%. There were 38.4% patients with a central line and the rate of CLABSI was 1.5%. The classifiers using deep learning performed with the highest AUC for mortality, 0.885±0.010 (p<0.01) and central line placement, 0.816±0.006 (p<0.01). The classifier using logistic regression for predicting CLABSI performed with an AUC of 0.722±0.048 (p<0.01). This study demonstrates models for identifying patients who will develop CLABSI. Early identification of these patients has implications for quality, cost, and outcome improvements. •Machine learning has proven to be useful for developing prediction models for outcomes in intensive care unit patients.•This study uses illness severity scores and comorbidities provided to train artificial intelligence classifiers.•These classifiers were highly accurate for predicting central line-associated bloodstream infections and mortality.•Such predictive models can be incorporated into existing medical record systems to support clinical decision making.