High-volume Level Research Articles

The impact of volume and neonatal level of care on outcomes of moderate and late preterm infants.

Evaluate the relationship of neonatal unit level of care (LOC) and volume with mortality or morbidity in moderate-late preterm (MLP) (32-36 weeks' gestation) infants. Retrospective cohort study of 650,865 inborn MLP infants in 4976 hospitals-years using 2003-2015 linked administrative data from 4 states. Exposure was combined neonatal LOC and MLP annual volume. The primary outcome was death or morbidity (respiratory distress syndrome, severe intraventricular hemorrhage, necrotizing enterocolitis, sepsis, infection, pneumothorax, extreme length of stay) with components as secondary outcomes. Poisson regression models adjusted for patient characteristics with a random effect for unit were used. In adjusted models, high-volume level 2 units had a lower risk of the primary outcome compared to low-volume level 3 units (aIRR 0.90 [95% CI 0.83-0.98] vs. aIRR 1.13 [95% CI 1.03-1.24], p < 0.001) CONCLUSION: MLP infants had improved outcomes in high-volume level 2 units compared to low-volume level 3 units in adjusted analysis.

Dedicated Chest Wall Injury Program quality review: How to create and incorporate a quality and safety program for surgical stabilization of rib fractures.

Adoption of surgical stabilization of rib fractures (SSRF) in chest trauma necessitates outcomes reviews and process improvement (PI). As volume and complexity increase, such vigilance is imperative. Over 10 years, our center has developed a dedicated PI program based on our trauma PI program. Here, we outline the components of this program, aiming to share best practices and potentially improve SSRF patient outcomes. Over 10 years, our dedicated SSRF PI process has evolved to include bimonthly reviews on case and quality metrics. In 2022, all patients at our single high-volume Level 1 trauma center with flail chest segments were identified, and a PI chart review was conducted. Data collected included management approach (operative vs. nonoperative), postoperative complications, mortality, patient demographics, trauma specific variables (Injury Severity Score, etc.), and rib fracture details. Operative data collected included number of ribs plated, system used, and complication rates for each surgeon and plating system used. Of 82 patients identified, 88% underwent SSRF. Among these, 49% experienced one or more postoperative complications, not all directly related to SSRF procedures. Mortality rate for SSRF patients was 15%, predominantly in those with Injury Severity Score of >25 and mean age of 58 years. Patients who had trauma activations and required emergency department chest tube placement had higher complications. The mean number of ribs stabilized was four. Complications occurred more frequently with posterior fractures. Outcomes were collated and analyzed at SSRF Outcomes Committee. The utilization of SSRF underscores the need for a rigorous quality review process to enhance patient safety and SSRF-specific outcomes. Our program developed over time from and was implemented in fashion similar to the trauma PI processes. The resulting quality initiative has fostered center-specific PI projects and programmatic advancements. Economic and Value-Base Evaluations; Level IV.

Ultrasound-Guided Lumbar Plexus-Sciatic Nerve Blocks Versus Epidurals for Orthopaedic Surgeries: A Study to Compare the Competency of Novice Anaesthesiology Residents in a High-Volume Level 1 Trauma Centre.

The relative merits of peripheral nerve blocks (PNB) over central neuraxial anaesthesia and the advantages of the above two techniques over general anaesthesia for surgical interventions of the lower limb are well established. The competency of anaesthetic trainees in a high-volume level 1 trauma centre in administering dual ultrasound and nerve stimulator-guided lumbar plexus-sciatic nerve block(DUNLuPS) vs. epidural anaesthesia (EA) was compared by reporting the adequacy of anaesthesia with the two techniques, time taken for the performance of block, time of onset of sensoryblock (TOSB), and time of onset of motor block (TOMB). This prospective, randomized, study enrolled 92 patients aged 18-80 years with lower limb fractures admitted in trauma triage and scheduled for surgery. Thepatients were randomly allocated equally into the EA group and the DUNLuPS group. A total of 20 anaesthesia trainees in the third year of residencywith clinical experience of more than 15 independent lumbar plexus-sciatic nerve blocks were included in the study.A volume of 20 ml of 0.5% ropivacaine was administered in the lumbar plexus (Shamrock technique) but the volume used for sciatic nerve (subgluteal approach) was varied so that the cumulative dose did not exceed 3 mg/kg. For each block, the onset of nerve blockade was assessed every five minutes, and the assessments continued for an additional 30 minutes after the nerve blocks were finished. Clinical characteristics and adequacy of anaesthesia were comparable, i.e., 95.65% and93.47% success in the EA (n = 46) and DUNLuPS (n = 46) groups, respectively. Performance time was significantly more in the DUNLuPS group but followed by significantly less TOSB and TOMB. The time for the first analgesic request was 351.63 ± 148.70 minutes in the DUNLuPS group and 147.60 ± 52.65 minutes in the EAgroup (p < 0.0001). Both EA and DUNLuPS provide effective and comparable intra-operative anaesthesia for orthopaedic lower limb surgeries (OLLS) when administered by residents with more than two years of experience (third year of residency)in ultrasound-guided regional nerve blocks in a high-volume level 1 trauma centre. Statistically significant differences in the block performance characteristicshad no clinical advantage as it was compensated by the faster onset time in the DUNLuPS group. Post-operative pain management was better in the DUNLuPS group, sothe practice and conduct of anaesthesia for trauma patients should focus on the establishment of "block rooms" and timely training of residents in the former so that the advantages can be extended to the patient population.

SHIMP Findings in Individuals Using Personal Listening Devices.

Listening to PLD at higher volume levels are known to cause subtle pre-clinical damage to the auditory system and vestibular end organs. Exposure to PLDs may also cause vestibular dysfunction much before the cochlear dysfunction. SHIMP is a newly described tool to assess the vestibulo-ocular reflex (VOR) gain suppression. With the premise that prolonged exposure to PLDs at high volume levels may cause vestibular dysfunction, and SHIMP being an early detector of vestibular dysfunction, the study was undertaken. The study aimed to describe the SHIMP test findings in normal hearing individuals with and without prolonged exposure to PLDs at > 60% of volume. A cross sectional comparative study was carried out on 128 participants with and without history of PLD exposure. Participants within the age range of 15-24years and history of PLD usage at < 60% volume for < 1year and at > 60% volume for > 1year were recruited for the study. Output dBSPLs delivered by PLDs were measured using microphone in the ear method. Further, SHIMP was administered to assess the vestibular function. The dBSPL levels used by the participants of both the groups were within the DRC used for occupational noise exposure. Likewise, no statistically significant difference was observed between the two groups. Participants using PLDs with dBSPLs within the DRC may not be at a crucial risk. However, one must use precautionary measures to prevent any subclinical or long-lasting damage to the inner ear.

Best Case/Worst Case-ICU: protocol for a multisite, stepped-wedge, randomised clinical trial of scenario planning to improve communication in the ICU in US trauma centres for older adults with serious injury

IntroductionPoor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called...

Using Next-Generation Sequencing to Understand Infection Prevention in Surgical Treatment of Upper Extremity Fractures-A Prospective Cohort Study.

Postoperative fracture site infection can lead to notable patient morbidity, increase cost of care, and further contribute to healthcare disparities globally. Dogma suggests surgical blades as a vehicle for introducing bacteria into the surgical site; however, there is a paucity of literature to support this claim. This study uses advanced DNA sequencing to detect bacterial DNA on surgical blades used in upper extremity fracture surgeries. This was a prospective study, conducted at a high-volume level 1 trauma center. All acute, closed upper extremity fractures requiring surgical stabilization were consecutively enrolled in a prospective fashion. The primary end point was the presence of bacterial DNA on the surgical blade using next-generation sequencing (NGS). At the time of surgery, two blades were sterilely opened. One blade served as the control while the other was used for the initial skin incision. Two negative control blades were opened directly into a sterile container. Two positive control blades were used for skin incision through known infections. All samples were sent for NGS analysis. Forty patients were enrolled in this study. The median age was 33.5 years, and 30% were female; the median body mass index was 26.52. Humerus fractures were the most common injury (N = 17, 42.5%), followed by clavicle fractures (13, 32.5%) and radius/ulna fractures (10, 25.0%). NGS analysis revealed no contamination of test blades used for skin incision. Three control blades tested positive for bacterial DNA. Negative control blades tested negative for bacterial DNA (0/2); the positive control blades resulted positive for bacterial DNA contamination (2/2). Surgical blades used for skin incision in the upper extremity are not contaminated with bacterial DNA as analyzed by NGS. This finding challenges previous surgical dogma regarding surgical blade contamination and supports that the same surgical blade can safely be used for deeper dissection. Level II study: IRB approval-IRB#848938.

Intraspecific and interspecific resource partitioning between bumblebee workers and males related to nectar quantity and quality.

Bumblebees are important pollinators for many natural and agricultural systems in temperate regions. Interspecific and intraspecific variation in floral resource preferences have been proposed to influence bumblebee community structure. In particular, sexual dimorphism is a major source of intraspecific niche variation. Although interspecific resource partitioning is well studied, few studies have explored the intraspecific dynamics between workers and males. Here, we report a study on a total of 11528 workers and 2220 males of 14 bumblebee species recorded over 5years in the Hengduan Mountains of Southwest China. We first compared the potential for interspecific and intraspecific competition between workers and males using visitation records and resource partitioning indices (overlap index). We then evaluated the influence of nectar traits on flower preference, including nectar volume and the levels of hexose, sucrose and 10 essential amino acids (EAAs). We found that the niche overlap between intraspecific workers and males was higher than that between different species, and temporal overlap alone did not strongly determine diet overlap. Males of most species preferred flowers with high levels of EAAs and hexose, whereas workers of some species preferred flowers with high nectar volume and sucrose levels. This study suggests that there is floral resource partitioning among bumblebee species, and between workers and males, which may play a key role in alleviating interspecific and intraspecific competition. These findings also provide a useful guide for which kinds of plants might be most valuable for bumblebees, especially the understudied males, in this biodiversity hotspot.

Early Fluid Is Less Fluid: Comparing Early Versus Late ICU Resuscitation in Severely Injured Trauma Patients.

The temporal trends of crystalloid resuscitation in severely injured trauma patients after ICU admission are not well characterized. We hypothesized early crystalloid resuscitation was associated with less volume and better outcomes than delaying crystalloid. Retrospective, observational. High-volume level 1 academic trauma center. Adult trauma patients admitted to the ICU with emergency department serum lactate greater than or equal to 4 mmol/dL, elevated lactate (≥ 2 mmol/L) at ICU admission, and normal lactate by 48 hours. None. For the 333 subjects, we analyzed patient and injury characteristics and the first 48 hours of ICU course. Receipt of greater than or equal to 500 mL/hr of crystalloid in the first 6 hours of ICU admission was used to distinguish early vs. late resuscitation. Outcomes included ICU length of stay (LOS), ventilator days, and acute kidney injury (AKI). Unadjusted and multivariable regression methods were used to compare early resuscitation vs. late resuscitation. Compared with the early resuscitation group, the late resuscitation group received more volume by 48 hours (5.5 vs. 4.1 L; p ≤ 0.001), had longer ICU LOS (9 vs. 5 d; p ≤ 0.001), more ventilator days (5 vs. 2 d; p ≤ 0.001), and higher occurrence rate of AKI (38% vs. 11%; p ≤ 0.001). On multivariable regression, late resuscitation remained associated with longer ICU LOS and ventilator days and higher odds of AKI. Delaying resuscitation is associated with both higher volumes of crystalloid by 48 hours and worse outcomes compared with early resuscitation. Judicious crystalloid given early in ICU admission could improve outcomes in the severely injured.

Fluoroscopy guided teardrop technique for open trans-muscular iliac screw placement and open reduction maneuvers during modified triangular spinopelvic fixation for unstable U-shaped sacral and tile C pelvic traumas: technical note.

Unstable traumas of the spinopelvic junction, which include displaced U-shaped sacral fractures (Roy-Camille type 2 and type 3) and Tile C vertical shear pelvic ring disruptions, occur in severe traumas patients following high speed traffic accident or fall from a height. These unstable traumas of the spinopelvic junction jeopardize one's ability to stand and to walk by disrupting the biomechanical arches of the pelvis, and may also cause cauda equina syndrome. Historically, such patients were treated with bed rest and could suffer a life-long burden of orthopedic and neurological disability. Since Schildhauer pioneer work back in 2003, triangular spinopelvic fixation, whether it is performed in a percutaneous fashion or by open reduction and internal fixation, allows to realign bone fragments of the spinopelvic junction and to resume walking within three weeks. Nevertheless, such procedure remains highly technical and it not encountered very often, even for spine surgeons working in high-volume level 1 trauma centers. Hence, this visual technical note aims to provide a few tips to guide less experience surgeons to complete this procedure safely.

Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres.

This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres. A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes. Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome. These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Whole blood versus balanced resuscitation in massive hemorrhage: Six of one or half dozen of the other?

Whole blood (WB) resuscitation is increasingly used at trauma centers. Prior studies investigating outcomes in WB versus component-only (CO) resuscitation have been limited by small cohorts, low volumes of WB resuscitation, and unbalanced CO resuscitation. This study aimed to address these limitations using data from a high-volume Level I trauma center, which adopted a WB-first resuscitation paradigm in 2018. We hypothesized that the resuscitation method, WB or balanced CO, would have no impact on patient mortality. A single-center, retrospective cohort study of adults presenting as a trauma activation from July 2016 through July 2021 was performed. Receipt of three or more units of WB or packed red blood cells (RBC) within the first hour of resuscitation was required for inclusion. Patients were grouped into WB versus CO resuscitation and important clinical outcomes were compared. Mortality was evaluated with Kaplan-Meier analysis, log-rank testing, and multivariable Cox proportional hazards modeling. There were 180 patients in the WB group and 170 patients in the CO group. Of the 180 WB patients, 110 (61%) received only WB during the first 24 hours. The WB group received a median of 5.0 units (interquartile range, 4.0-8.0) of WB and CO group received a median of 6.0 units (interquartile range, 4.0-11.8) of RBCs during the first 24 hours of resuscitation. In the CO group, median RBC/plasma and RBC/platelet ratios approximated 1:1:1. Groups were similar in clinicopathologic characteristics including age, Injury Severity Score, mechanism of injury, and requirement for hemorrhage control interventions (WB 55% vs. CO 59%, p = 0.60). Unadjusted survival was equivalent at 24 hours ( p = 0.52) and 30 days ( p = 0.70) between both groups on Kaplan-Meier analysis with log-rank testing. On multivariable Cox regression, WB resuscitation was not independently associated with improved survival after accounting for age, Injury Severity Score, mechanism of injury, and receipt of hemorrhage control procedure (hazard ratio, 0.85; 95% confidence interval, 0.61-1.19, p = 0.34). Balanced CO resuscitation is associated with similar mortality outcomes to that of WB based resuscitation. Therapeutic/Care Management; Level IV.

Acute versus staged fixation of bicondylar tibial plateau fractures: a dual centre international study.

Bicondylar tibial plateau fractures pose many treatment challenges due to their complex fracture patterns and associated soft tissue compromise. We aim to evaluate outcomes of acute ORIF (aORIF) versus staged ORIF (sORIF) of high energy bicondylar tibial plateau fractures. We retrospectively reviewed 186 patients at two high-volume Level I trauma centers. One hundred one patients underwent aORIF and 85 underwent sORIF between 2011 and 2019. Clinical outcomes of interest included operative time, wound dehiscence, superficial and deep infection, nonunion, flap coverage, arthrodesis, and early conversion to arthroplasty. Patients had a median follow up of 12months (6-98months). The sORIF group had a higher ISS (p = 0.02) and a higher rate of open fractures (24.7% vs 11.9%, p = 0.03). The groups were statistically similar in other demographics and co-morbidities. Operative time was significantly shorter in the aORIF group (157 vs 213min., p < 0.001). There was no statistical difference in wound dehiscence, deep infection, flap coverage, nonunion, unplanned reoperation, or post-traumatic arthritis between groups. However, aORIF was associated with a significantly lower rate of superficial infection (p = 0.01), arthroplasty (p = 0.003) and unplanned reoperation (p = 0.005). Subgroup analysis of only the 41C3 fractures showed a lower rate of superficial infections in the aORIF group (p = 0.04). No difference in complications was found between the fracture subgroups. We found no increased risk of complications with aORIF compared to sORIF for bicondylar tibial plateau fractures. While not all injuries may be appropriate for aORIF, our results demonstrate the safety of aORIF when patients are properly selected by experienced fracture surgeons. Level III.

Management of gunshot wounds near the elbow: experiences at a high-volume level I trauma center.

Gunshot-related fractures near the elbow are challenging, and available data to guide the practitioner are lacking. This report analyzes injury patterns and treatment strategies in a case series from a high-volume urban trauma center. All periarticular gunshot fractures near the elbow treated at a level 1 trauma center from 2014 to 2018 were retrospectively reviewed. Fracture location, patient demographics, concomitant injuries, treatment modalities, and complications were analyzed. Twenty-four patients were identified. All patients received prophylactic antibiotics upon admission and underwent urgent surgical debridement. Open reduction and internal fixation (ORIF) was performed with initial debridement in 22 of 24 patients. Seven patients sustained distal humerus fractures, 10 patients sustained isolated proximal ulna or proximal radius fractures, and seven had combined fracture patterns. Eleven patients presented with nerve palsy, and two had transected nerves. Two patients had vascular injury requiring repair. One patient required a temporary elbow-spanning external fixator and underwent staged debridement followed by ORIF. One patient with a grade IIIC fracture developed a deep infection that precluded ORIF. One patient required revision ORIF due to fracture displacement. This investigation reports on management of ballistic fractures near the elbow at a busy urban level I trauma center. Our management centered on rapid debridement, early definitive fixation, and intravenous antibiotic administration. We report on associated neurovascular injury, bone loss, and other challenges in this patient population. Level of evidence: IV.

Research on Forecasting the Yield of China's Commodity Futures Market Based on the Intraday Momentum Effect

By exploring the intraday momentum effect of the Chinese commodity futures market, it was found that there is a significant intraday momentum effect in the Chinese commodity futures market. The first half hour return of night opening and the first half hour return of day opening can significantly predict the first half hour return of closing within and outside the sample. Furthermore, it was found that the momentum effect of commodity futures is more significant at high trading volume and high volatility levels. The momentum strategy constructed based on the intraday momentum effect can significantly outperform the benchmark strategy, providing investors with a robust investment strategy.

ICU Readmission in Injured Older Adults: Modifiable Risk Factors and Implications.

Prior evaluations of ICU readmission among injured older adults have inconsistently identified risk factors, with findings limited by use of sub-analyses and small sample sizes. This study aimed to identify risk factors for and implications of ICU readmission in injured older adults. This retrospective, single-center cohort study was conducted at a High-Volume Level 1 Trauma Center and included injured older adult patients (>65 years old) requiring at least one ICU admission during hospitalization between 2013-2018. Patients who died <48 hours of admission were excluded. Exposures included patient demographics and clinical factors. The primary outcome was ICU readmission. Multi-variable regression was used to identify risk factors for ICU readmission. 6,691 injured adult trauma patients were admitted from 2013-2018, 55.4% (n = 3,709) of whom were admitted to the ICU after excluding early deaths. Of this cohort, 9.1% (n = 339) were readmitted to the ICU during hospitalization. Readmitted ICU patients had a higher median Injury Severity Score (21 (IQR: 14-26) vs 16 (IQR: 10-24)), with similar mechanisms of injury between the two groups. Readmitted ICU patients had a significantly higher mortality (19.5%) compared to single ICU admission patients (9.9%) (p < 0.001) and higher rates of developing any complication, including delirium (61% vs 30%, p < 0.001). On multivariable analysis, the factors associated with the highest risk of readmission were delirium (RR = 2.6, 95% CI 2.07 - 3.26) and aspiration (RR = 3.04, 95% CI 1.67- 5.54). More patients in the single ICU admission cohort received comfort-focused care at the time of their death as compared to the ICU readmission cohort (93% vs 85%, p = 0.035). Readmission to the ICU is strongly associated with higher mortality for injured older adults. Efforts targeted at preventing respiratory complications and delirium in the geriatric trauma population may decrease the rates of ICU readmission and related mortality risk. III/Epidemiologic.

Isolated thoracic and lumbar transverse process fractures: Do they need spine surgeon evaluation? a high volume level I trauma center experience with cost analysis

BackgroundTransverse process fractures (TPF) of the thoracic and lumbar spine have become increasingly identified due to CT imaging. Spine service consultation is common for further evaluation and management. There are several studies that demonstrate no difference in clinical outcome with or without spine service intervention. However, no study to our knowledge provides an additional cost analysis. We hypothesize that isolated thoracolumbar TPF are stable injuries. Furthermore, spine service consultation and evaluation results in increased health care costs. MethodsPatients were identified using trauma registry data at Saint Louis University (SLU) from January 2012 to August 2018. Chart and imaging review was performed to determine if additional spine fractures were identified by the spine team which were not included in the initial radiology report. TPF associated with other spinal injuries were defined as one or more thoracic and/or lumbar TPF in addition to any other acute fracture or dislocation in the cervical, thoracic, or lumbar spine. A separate cost analysis with institution-specific charges was also performed. ResultsSix hundred eighty-two patients with TPF from January 2012 to August 2018 were identified. Two hundred twenty-eight patients met the criteria to be included in this study. Additional spinal pathology that was not included in the initial radiology report was identified in 5 (2.19%) patients, none of which required surgical intervention. Cost analysis demonstrated additional costs associated with spine service intervention totaled $1,725,360.28. Average cost per patient in our cohort summed to $2,529.85 ConclusionsThese data support that isolated TPF of the thoracic and lumbar spine are stable injuries that likely do not require spine service intervention and in fact may represent unnecessary financial burden. Foregoing unnecessary consultation can alleviate time constraints within spine service practices and reduce health care costs by eliminating costly extraneous interventions from the patient's care.

In- and out-of-hospital outcomes following surgical stabilization of rib fractures in 80 years and older: A single-institution experience

BackgroundSurgical stabilization of rib fractures (SSRF) has demonstrated benefit in patients with flail chest and multiple displaced fractures. There is mounting evidence for SSRF following chest wall injury (CWI) for the geriatric trauma population. A recent multi-center retrospective study highlighted a mortality benefit even for those patients aged 80 years and older. The objective of this investigation was to review our institutional experience with both in- and out-of-hospital outcomes within this patient population following SSRF. MethodsA retrospective review of patients 80 years and older was performed at a high-volume level 2 trauma center from 2017 to 2021. SSRF volume is routinely >60 cases per year. Perioperative, inpatient, and outpatient data were collected as available. Primary outcomes were inpatient and 90-day mortality. Secondary outcomes included discharge on narcotics and freedom from narcotics at 30 days. Results50 patients were included for review. Mean age was 86 years and mechanism of injury was most often fall. 28 of 50 (56%) patients had flail chest (radiographic). Mean number of ribs fixated was 4.7 and time to surgery 2.5 days. Inpatient mortality was 3/50 (6%), 90-day mortality was 9/50 (18%) of which three were attributable primarily to CWI (6/50, 12%). Of patients with follow-up of 1 year and beyond, 27/28 were alive (96%). With respect to narcotic consumption, 45% (21/47) were discharged on narcotics with 90% (28/31; N limited by missing data) being narcotic-free at 30 days. ConclusionIn this high-risk patient population, inpatient mortality was comparably low to prior reports, though 90-day mortality was doubled when incorporating CWI-related deaths. Narcotic use was seen in the minority of patients upon discharge, and most progressed to being narcotic-free at 30 days post-hospitalization. Inpatient outcomes alone may not adequately define both the benefit and risk of SSRF performed in patients 80 years and older.

Blunt traumatic female urethral and bladder neck injuries: a 15-year single-institution experience.

To describe our experience in the management and outcomes of female patients with urethral or bladder neck (BN) injury at a high-volume Level 1 trauma center. A retrospective chart review of all female patients with urethral or BN injury by blunt trauma mechanism admitted to a Level 1 trauma center between 2005 and 2019 was performed. Ten patients met study criteria with median age 36.5years. All had concomitant pelvic fractures. All injuries were confirmed operatively, with no delayed diagnoses. Two patients were lost to follow up. One patient was not eligible for early repair of urethral injury and had two repairs of a urethrovaginal fistula. Two of seven (29%) patients who underwent early repair of their injury had an early Clavien grade > 2 complication, with none reporting long-term complications at median follow-up of 15.2months. Intraoperative evaluation is critical in the diagnosis of female urethral and BN injury. In our experience, acute surgical complications are not uncommon after the management of such injuries. However, there were no reported long-term complications in those patients who had prompt management of their injury. This aggressive diagnostic and surgical strategy is instrumental in attaining excellent surgical outcomes.

Incorporating hydrothermal liquefaction into wastewater treatment – Part III: Aqueous phase characterization and evaluation of on-site treatment

For the incorporation of the hydrothermal liquefaction (HTL) process into wastewater treatment plants (WWTPs), the liquid by-product of the process, named HTL aqueous, creates the biggest bottleneck because of its high volume and contaminant levels. In this study, an extensive characterization of various HTL aqueous samples, obtained from the liquefaction of mixed sludge cake at 290–360 °C and 0–30 min, was performed. From the most to least abundant, compounds found in HTL aqueous samples were N-heterocyclics, volatile fatty acids (VFAs), amides, ketones, amines, and phenolics. The characteristics that make HTL aqueous suitable for biological treatment were pH, alkalinity, macro- and micro-nutrients. However, along with N-heterocyclic compounds, total ammonia levels of 3.9–7.1 g/L and total phenol levels of 1.5–2.3 g/L were identified as compounds that would potentially inhibit biological treatment processes. The chemical oxygen demand (COD) levels of HTL aqueous samples were 87–103 g/L. HTL aqueous obtained under 325 °C-0 min (no retention at 325 °C) condition was identified as the most suitable for biological treatment owing to its high VFA (17 g/L), carbohydrate (827 mg/L), and low phenol (1.6 g/L) concentrations. By increasing HTL reaction severity (temperature and retention time), COD, dissolved protein, total carbohydrate, total phenol, and total short-chain VFA levels decreased, whereas total ammonia, pH, alkalinity, valeric acid, and iso-valeric acid concentrations increased. Regression analysis was used to obtain equations that reveal patterns between HTL reaction parameters and aqueous phase characteristics. Overall, a pretreatment application was found necessary for the detoxification of HTL aqueous before biological treatment.

Trends in Resources for Neonatal Intensive Care at Delivery Hospitals for Infants Born Younger Than 30 Weeks’ Gestation, 2009-2020

In an ideal regionalized system, all infants born very preterm would be delivered at a large tertiary hospital capable of providing all necessary care. To examine whether the distribution of extremely preterm births changed between 2009 and 2020 based on neonatal intensive care resources at the delivery hospital. This retrospective cohort study was conducted at 822 Vermont Oxford Network (VON) centers in the US between 2009 and 2020. Participants included infants born at 22 to 29 weeks' gestation, delivered at or transferred to centers participating in the VON. Data were analyzed from February to December 2022. Hospital of birth at 22 to 29 weeks' gestation. Birthplace neonatal intensive care unit (NICU) level was classified as A, restriction on assisted ventilation or no surgery; B, major surgery; or C, cardiac surgery requiring bypass. Level B centers were further divided into low-volume (<50 inborn infants at 22 to 29 weeks' gestation per year) and high-volume (≥50 inborn infants at 22 to 29 weeks' gestation per year) centers. High-volume level B and level C centers were combined, resulting in 3 distinct NICU categories: level A, low-volume B, and high-volume B and C NICUs. The main outcome was the change in the percentage of births at hospitals with level A, low-volume B, and high-volume B or C NICUs overall and by US Census region. A total of 357 181 infants (mean [SD] gestational age, 26.4 [2.1] weeks; 188 761 [52.9%] male) were included in the analysis. Across regions, the Pacific (20 239 births [38.3%]) had the lowest while the South Atlantic (48 348 births [62.7%]) had the highest percentage of births at a hospital with a high-volume B- or C-level NICU. Births at hospitals with A-level NICUs increased by 5.6% (95% CI, 4.3% to 7.0%), and births at low-volume B-level NICUs increased by 3.6% (95% CI, 2.1% to 5.0%), while births at hospitals with high-volume B- or C-level NICUs decreased by 9.2% (95% CI, -10.3% to -8.1%). By 2020, less than half of the births for infants at 22 to 29 weeks' gestation occurred at hospitals with high-volume B- or C-level NICUs. Most US Census regions followed the nationwide trends; for example, births at hospitals with high-volume B- or C-level NICUs decreased by 10.9% [95% CI, -14.0% to -7.8%) in the East North Central region and by 21.1% (95% CI, -24.0% to -18.2%) in the West South Central region. This retrospective cohort study identified concerning deregionalization trends in birthplace hospital level of care for infants born at 22 to 29 weeks' gestation. These findings should serve to encourage policy makers to identify and enforce strategies to ensure that infants at the highest risk of adverse outcomes are born at the hospitals where they have the best chances to attain optimal outcomes.