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Splenic angioembolization (SAE) is increasingly used in the management of splenic injuries in adults, although its value in pediatric trauma is unclear. We sought to assess outcomes related to splenectomy vs SAE. The National Trauma Data Bank was queried for patients 0 to 15 years of age from 2007 to 2011. Subgroup analysis of splenectomy vs SAE was performed for high-grade injuries using propensity analysis and inverse probability weighting. Of 11,694 children presenting with splenic trauma, over 90% were treated nonoperatively. Adjusted analysis of high-grade injuries included 265 children who underwent splenectomy and 199 who underwent SAE. The Injury Severity Score, number of transfusions, and complications rates were not significantly different between the 2 groups. Overall adjusted mortality for children with high-grade injuries was 13.4% following splenectomy and 10.0% following SAE (P = .31) Patients undergoing SAE for high-grade splenic trauma have comparable morbidity and mortality with splenectomy. •Splenectomy was compared with splenic angioembolization for management of splenic trauma in children.•Less than 10% of the children require intervention for splenic injury.•There was no difference in transfusion rates or postprocedural complications.•Mortality rates between the 2 groups were not statistically different.

The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remains unclear. We hypothesized patients with delayed transfer to operating room (OR) would benefit from REBOA. Using the 2016–2017 ACS-TQIP database, patients were divided based on the transfer time to OR: ≤1 h (early) and >1 h (delayed). In each group, patients who underwent REBOA in emergency department (ED-REBOA) were matched with those without REBOA (non-REBOA) using propensity scores, and survival to discharge was compared. Among 163,453 patients, 114 and 138 patients (38 and 46 ED-REBOA) were included in the early and delayed groups, respectively. Survival to discharge was comparable between ED-REBOA and non-REBOA patients in the early group (39.5% vs. 48.7%, p = 0.35), whereas it was higher in ED-REBOA patients in the delayed group (39.1% vs. 12.0%, p < 0.01). Patients with delayed transfer to OR >1 h benefited from REBOA. •Patients transferred to the OR within 1 h after arrival did not benefit from REBOA.•Patients with delays in transfer to the OR >1 h benefited from REBOA at the ED.•REBOA was associated with increased survival to discharge when transfer was delayed.

Presented September 24, 2011, at the 92 nd annual meeting of the New England Surgical Society, September 23–25, 2011, Mt. Washington, New Hampshire.

Introduction This study aimed to determine the correlation between trauma patient co-morbidities, insurance status and final disposition. Methods We evaluated the impact of co-morbid conditions and insurance status on trauma patient outcomes utilising the National Trauma Data Bank. Paired T-tests were used to determine significance (P < 0.05). Results Patients who were discharged to home had the highest rate of private insurance (27%, P < 0.01), while those sent to a facility had the highest rate of public insurance such as Medicare or Medicaid (50%, P < 0.01) and the lowest rate of no insurance (5%, P < 0.01). Patients who died had the lowest rate of private insurance (17%, P < 0.01) and 15% had no insurance (P < 0.01). Complications and co-morbidities were significantly more common in patients who died compared to those sent to another facility or home. Conclusion Improving access to private insurance is associated with improved trauma-related morbidity and mortality.

Since Stanley Dudrick's seminal work and publication of parenteral nutrition in the late 1960s, alternatives to delivering the maximum amount of micro- and macronutrients have been ferociously debated. Among clinicians, patients, and even hospital administrators, few can deny the contributions of enteral and parenteral nutrition to the routine or critically ill patient. Research continues to improve parenteral nutrition formulae for in adults and children. The debates of enteral versus parenteral nutrition continue but they should be evidenced based. Both references hold significant importance regardless of topic, and the subject of initiating early versus late parenteral nutrition in the intensive care unit should also be evidence based. The ability of a surgeon at the time of an operation to predict gastroparesis or a postoperative ileus has yet to be investigated, and as such it proves challenging to determine which patient requires immediate postoperative nutritional support.

Background Controversy exists about the timing of the initiation of parenteral nutrition in critically ill adults in whom caloric targets cannot be met by enteral nutrition alone. Methods In this randomized, multicenter trial, we compared early initiation of parenteral nutrition (European guidelines) with late initiation (American and Canadian guidelines) in adults in the intensive care unit (ICU) to supplement insufficient enteral nutrition. In 2312 patients, parenteral nutrition was initiated within 48 hours after ICU admission (early-initiation group), whereas in 2328 patients, parenteral nutrition was not initiated before day 8 (late-initiation group). A protocol for the early initiation of enteral nutrition was applied to both groups, and insulin was infused to achieve normoglycemia. Results Patients in the late-initiation group had a relative increase of 6.3% in the likelihood of being discharged alive earlier from the ICU (hazard ratio, 1.06; 95% 255confidence interval [CI], 1.00−1.13; P = 0.04) and from the hospital (hazard ratio, 1.06; 95% CI, 1.00−1.13; P = 0.04), without evidence of decreased functional status at hospital discharge. Rates of death in the ICU and in the hospital and rates of survival at 90 days were similar in the two groups. Patients in the late-initiation group, as compared with the early-initiation group, had fewer ICU infections (22.8% vs. 26.2%, P = 0.008) and a lower incidence of cholestasis (P < 0.001). The late-initiation group had a relative reduction of 9.7% in the proportion of patients requiring more than 2 days of mechanical ventilation (P = 0.006), a median reduction of 3 days in the duration of renal-replacement therapy (P = 0.008), and a mean reduction in health care costs of €1110 (about $1600) (P = 0.04). Conclusions Late initiation of parenteral nutrition was associated with faster recovery and fewer complications, as compared with early initiation. (Funded by the Methusalem Program of the Flemish Government and others; EPaNIC ClinicalTrials.gov Number, NCT00512122.) Controversy exists about the timing of the initiation of parenteral nutrition in critically ill adults in whom caloric targets cannot be met by enteral nutrition alone. Late initiation of parenteral nutrition was associated with faster recovery and fewer complications, as compared with early initiation. The deleterious effect of early- parenteral nutrition on muscle force was explained by inhibition of autophagy, an intracellular mechanism for damage clearing. These data and detailed analyses of the relation between macronutrient intake and outcome in EPaNIC and PEPaNIC revealed that not the parenteral route per se, but the early high dose of-particularly-amino acids may have hampered recovery.

Paleopathological evidence and descriptions of upper gastrointestinal bleeds (UGIB), i.e., proximal to the ligament of Treitz, are limited and sometimes inconclusive. The earliest potential reference to UGIB can be traced to the Ebers Papyrus (circa 1550 BC) describing a “blood-nest” in a patient who acutely turned pale and later expired (Brothwell DR, Sandison AT. Diseases in antiquity: a survey of the diseases, injuries, and surgery of early populations. Springfield, Ill.: Thomas; 1967. xix, 766 p.). A more conclusive familiarity of peptic ulcer pathology was noted by Roman scientists during the first century and thus we know that UGIB have been known for at least 2000 years (Majno G. The healing hand: man and wound in the ancient world. Cambridge, MA: Harvard University Press; 1975. xxiii, 571 p., 6 leaves of plates p.). Risk factors for UGIB were most likely omnipresent and, as such, suffering from UGIB has more than likely always plagued humans.

AbstractObjectivesTo characterize the clinical severity of covid-19 associated with the alpha, delta, and omicron SARS-CoV-2 variants among adults admitted to hospital and to compare the effectiveness of mRNA vaccines to prevent hospital admissions related to each variant.DesignCase-control study.Setting21 hospitals across the United States.Participants11 690 adults (≥18 years) admitted to hospital: 5728 with covid-19 (cases) and 5962 without covid-19 (controls). Patients were classified into SARS-CoV-2 variant groups based on viral whole genome sequencing, and, if sequencing did not reveal a lineage, by the predominant circulating variant at the time of hospital admission: alpha (11 March to 3 July 2021), delta (4 July to 25 December 2021), and omicron (26 December 2021 to 14 January 2022).Main outcome measuresVaccine effectiveness calculated using a test negative design for mRNA vaccines to prevent covid-19 related hospital admissions by each variant (alpha, delta, omicron). Among patients admitted to hospital with covid-19, disease severity on the World Health Organization’s clinical progression scale was compared among variants using proportional odds regression.ResultsEffectiveness of the mRNA vaccines to prevent covid-19 associated hospital admissions was 85% (95% confidence interval 82% to 88%) for two vaccine doses against the alpha variant, 85% (83% to 87%) for two doses against the delta variant, 94% (92% to 95%) for three doses against the delta variant, 65% (51% to 75%) for two doses against the omicron variant; and 86% (77% to 91%) for three doses against the omicron variant. In-hospital mortality was 7.6% (81/1060) for alpha, 12.2% (461/3788) for delta, and 7.1% (40/565) for omicron. Among unvaccinated patients with covid-19 admitted to hospital, severity on the WHO clinical progression scale was higher for the delta versus alpha variant (adjusted proportional odds ratio 1.28, 95% confidence interval 1.11 to 1.46), and lower for the omicron versus delta variant (0.61, 0.49 to 0.77). Compared with unvaccinated patients, severity was lower for vaccinated patients for each variant, including alpha (adjusted proportional odds ratio 0.33, 0.23 to 0.49), delta (0.44, 0.37 to 0.51), and omicron (0.61, 0.44 to 0.85).ConclusionsmRNA vaccines were found to be highly effective in preventing covid-19 associated hospital admissions related to the alpha, delta, and omicron variants, but three vaccine doses were required to achieve protection against omicron similar to the protection that two doses provided against the delta and alpha variants. Among adults admitted to hospital with covid-19, the omicron variant was associated with less severe disease than the delta variant but still resulted in substantial morbidity and mortality. Vaccinated patients admitted to hospital with covid-19 had significantly lower disease severity than unvaccinated patients for all the variants.

Abstract Background This document presents the American Thoracic Society clinical practice guidelines for the diagnosis of primary ciliary dyskinesia (PCD). Target Audience Clinicians investigating adult and pediatric patients for possible PCD. Methods Systematic reviews and, when appropriate, meta-analyses were conducted to summarize all available evidence pertinent to our clinical questions. Evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach for diagnosis and discussed by a multidisciplinary panel with expertise in PCD. Predetermined conflict-of-interest management strategies were applied, and recommendations were formulated, written, and graded exclusively by the nonconflicted panelists. Three conflicted individuals were also prohibited from writing, editing, or providing feedback on the relevant sections of the manuscript. Results After considering diagnostic test accuracy, confidence in the estimates for each diagnostic test, relative importance of test results studied, desirable and undesirable direct consequences of each diagnostic test, downstream consequences of each diagnostic test result, patient values and preferences, costs, feasibility, acceptability, and implications for health equity, the panel made recommendations for or against the use of specific diagnostic tests as compared with using the current reference standard (transmission electron microscopy and/or genetic testing) for the diagnosis of PCD. Conclusions The panel formulated and provided a rationale for the direction as well as for the strength of each recommendation to establish the diagnosis of PCD.