Need For Operative Management Research Articles

Dog bites are increasing in frequency and severity – a sustained effect following the COVID-19 pandemic

The COVID-19 pandemic and subsequent lockdown measures have changed various aspects of society, including patterns of human-animal interactions. This audit investigates the incidence and severity of dog bites admitted under the plastic surgery department at a major trauma centre before and after COVID-19 lockdowns. We assessed trends in dog bite cases over the course of one year (2018) prior to the COVID-19 lockdown and one year after (2022). A time period during COVID-19 lockdown itself was not included to avoid confounding factors due to changes in healthcare provision during the pandemic. Our analysis reveals a 47 % increase in dog bites after lockdowns ended compared to before. We also demonstrate statistically significant increases in the need for operative management (90 % of patients compared to 78 %) and length of inpatient hospital stay (average 63 h compared to 51). Moreover we show that dog bites have increased in severity, with a clear increase in patients presenting with deeper tissue injuries, tissue loss and muscle, nerve, vascular or bone involvement. This represents a significant functional, cosmetic and psychological impact for patients as well as financial impact on the NHS and increased workload for plastic surgery departments. This is the first paper to examine the severity of dog bite injuries and to demonstrate a sustained effect even after the easing of lockdown measures. Our findings shed light on the potential impact of lockdown measures on human-dog interactions and highlight the importance of public awareness and prevention strategies in mitigating dog bites. Lay summaryOur study demonstrates that dog bite injuries increased in frequency by 47 % following COVID-19 lockdowns. Patients with dog bites are also being admitted for longer than before, requiring more operations and have more severe injuries, with some requiring skin grafting, nerve repair or more complex plastic surgery reconstruction.

Prognostic factors to identify resolution of small bowel obstruction without need for operative management: systematic review

ObjectivesTo identify imaging, clinical, and laboratory variables potentially prognostic for surgical management of small bowel obstruction.MethodsTwo researchers systematically reviewed indexed literature 2001–2021 inclusive for imaging, clinical, and laboratory variables potentially predictive of surgical management of small bowl obstruction and/or ischaemia at surgery, where performed. Risk of bias was assessed. Contingency tables for variables reported in at least 5 studies were extracted and meta-analysed to identify strong evidence of association with clinical outcomes, across studies.ResultsThirty-one studies were ultimately included, reporting 4638 patients (44 to 313 per study). 11 (35%) studies raised no risk of bias concerns. CT was the modality reported most (29 studies, 94%). Meta-analysis of 21 predictors identified 5 strongly associated with surgical intervention, 3 derived from CT (peritoneal free fluid, odds ratio [OR] 3.24, 95%CI 2.45 to 4.29; high grade obstruction, OR 3.58, 95%CI 2.46 to 5.20; mesenteric inflammation, OR 2.61, 95%CI 1.94 to 3.50; abdominal distension, OR 2.43, 95%CI 1.34 to 4.42; peritonism, OR 3.97, 95%CI 2.67 to 5.90) and one with conservative management (previous abdominopelvic surgery, OR 0.58, 95%CI 0.40 to 0.85). Meta-analysis of 10 predictors identified 3 strongly associated with ischaemia at surgery, 2 derived from CT (peritoneal free fluid, OR 3.49, 95%CI 2.28 to 5.35; bowel thickening, OR 3.26 95%CI 1.91 to 5.55; white cell count, OR 4.76, 95%CI 2.71 to 8.36).ConclusionsSystematic review of patients with small bowel obstruction identified four imaging, three clinical, and one laboratory predictors associated strongly with surgical intervention and/or ischaemia at surgery.Clinical relevance statementVia systematic review and meta-analysis, we identified imaging, clinical, and laboratory predictors strongly associated with surgical management of small bowel obstruction and/or ischaemia. Multivariable model development to guide management should incorporate these since they display strong evidence of potential utility.Key Points• While multivariable models incorporating clinical, laboratory, and imaging factors could predict surgical management of small bowel obstruction, none are used widely.• Via systematic review and meta-analysis we identified imaging, clinical, and laboratory variables strongly associated with surgical management and/or ischaemia at surgery.• Development of multivariable models to guide management should incorporate these predictors, notably CT scanning, since they display strong evidence of potential utility.

Ulnar Variance in Athletes: A Scoping Review.

Ulnar variance (UV) is a measurement of the relative locations of the radius and ulna that may become perturbed in athletic populations. Positive UV can be associated with wrist pathologies often treated conservatively or surgically and may result in interruption of sports participation. This scoping review aims to summarize diagnostic measures of UV in athletes, describe its relation to separate wrist conditions, and present treatment strategies for symptomatic UV. A systematic search was created and modified for PubMed, CINAHL, Embase, and SPORTDiscus including articles from inception until February 2, 2022. Articles including UV characterization, imaging modality style, and an athletic population were searched across multiple databases. A scoping review was designed to identify the methods for imaging UV in athletic populations following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Level 4. The specific athletic population, imaging modality, measurement style, wrist pathology association, and surgical management of UV were extracted. A total of 4321 records were screened independently for eligibility: 22 met inclusion criteria. Eight sports comprised the analysis. All studies referenced conventional radiography to diagnose UV; 50% specified the posteroanterior, 18.2% anteroposterior, and 13.6% pronated, gripping radiographs. Hafner's method (7×), Palmer's technique (2×), and the method of perpendiculars (3×) were used to measure UV. Athletes displayed more positive UV than nonathletes and UV became more positive over time in longitudinal studies. Triangular fibrocartilage complex tears, focal lunate necrosis, and ulnar abutment were associated with positive UV. Ulnar shortening osteotomy was the most performed operation for positive UV. Conventional radiography is the gold standard for imaging UV in athletes. Hafner's method is the most commonly used radiograph measurement technique. Wrist pathology in athletic populations may indicate positive UV in need for operative management.

CASS – A cost-effective strategy in the management of blunt trauma abdomen

Background: Abdominal trauma is one of the leading causes of morbidity and mortality in both developing and developed countries. Management of blunt trauma abdomen (BTA) relies on most importantly, the clinical presentation of the patient. Aims and Objectives: This study aims at determining the accuracy of the clinical abdominal scoring system (CASS) in predicting the need for operative management of blunt abdominal trauma patients and also comparing the CASS score with the American association for the surgery of trauma – computed tomography (AAST CT) score. Materials and Methods: A total of 50 patients with BTA presenting to the Government tertiary care center Mysore were evaluated for age, sex, type of trauma, systolic blood pressure, Glasgow coma scale, pulse rate, time of presentation after trauma, abdominal clinical findings, respiratory rate, and hemoglobin concentration. Radiological investigations were done as indicated. CASS score was calculated and a comparison of the same with CT findings, in determining the need for laparotomy, was studied. Patients with co-existing head injuries and comorbidities were excluded from the study. Results: Among 50 cases, 44 were male accounting for 88% of the study population and 6 were female. The majority belonged to 18–30 years of age, accounting for 46%. In 42% of cases, a road trafficaccident was the mode of injury, followed by a fall from height in 4%. Latent period 52% of cases presented to the hospital between 0 and 6 h of the incident. 10% associated chest injuries. 42% showed splenic injury, thereby making it the most commonly injured organ. 28% had the liver injury. 28% had hemoperitoneum with source of bleed being unknown. Conclusion: CASS is a reliable and promising scoring system with sensitivity comparable to AAST CT grading in determining the need for surgical intervention in BTA patients. CASS provides an effective means of saving time and resources and gives the added advantage of avoiding expenses to underprivileged patients in our country.

Identifying Radiographic and Clinical Indicators to Reduce the Occurrence of Nontherapeutic Laparotomy for Blunt Bowel and Mesenteric Injury.

Roughly 5% of patients with blunt abdominal trauma (BAT) have a blunt bowel and/or mesenteric injury (BBMI). Determining the need for operative management in these patients can be challenging when hemodynamically stable. Single center studies have proposed scoring systems based on CT findings to guide management. Our study aimed to determine the predictability of abdominopelvic CT scan (CT A/P) findings in conjunction with clinical exam to determine the necessity of operative intervention for BBMI. Patients presenting from 2017 to 2022 to the University of South Alabama Level 1 Trauma Center after motor vehicle collision were retrospectively reviewed. Patients with CT findings suggestive of BBMI were further analyzed, noting CT findings, Glasgow coma scale (GCS), shock index, abdominal exam, operative or nonoperative management, and intraoperative intervention. 1098 patients with BAT underwent CT A/P. 139 patients had ≥1 finding suggestive of BBMI. 38 patients underwent surgical exploration and 30 had surgically confirmed BBMI. 27 patients required intervention for BBMI. Univariate analysis indicated that pneumoperitoneum (p < 0.0001), active extravasation of contrast (p = 0.0001), hemoperitoneum without solid organ injury (SOI) (p < 0.0001), peritonitis (p < 0.0001), and mesenteric stranding(p < 0.05) were significantly associated with intervention. In total, 30 patients had surgically confirmed BBMI. Active extravasation, pneumoperitoneum, hemoperitoneum without SOI, mesenteric stranding, and peritonitis were significant indicators of BBMI requiring intervention. CT and clinical findings cannot reliably predict the need for surgical intervention without ≥1 of these findings. Initial nonoperative management with serial clinical exams should be strongly considered to reduce incidence of nontherapeutic laparotomies.

Is Maxillofacial Gunshot Wound Location Associated With Operative Intervention?

Gunshot wound (GSW) injuries are an important public health concern in the United States. The study purpose was to measure the association between GSW location and need for operative treatment. This was a retrospective cohort study. Sample consisted of all patients treated for maxillofacial gunshot wound injuries at Cook County Health from 2008 to 2018. The sample data were collected through a retrospective charts review and review of computed tomography imaging. The predictor variable was the region of the face involved with the GSW and it was divided into 3 levels, upper face (UF), middle face (MF), and lower face (LF). The outcome variable was whether operative intervention was rendered or not (operative vs no intervention). Other variables of interest collected included patient demographics, the type of surgical intervention, disposition (home vs rehab/morgue), rate of intracranial injury, and need for blood transfusion. Data analysis was performed using Chi-square for proportions and relative risk (RR) with 95% confidence interval (CI). A total of 180 patients were identified to have sustained GSW injuries to the face during abovementioned time frame. Of those, 120 patients had isolated GSW injuries with no other organs involvement. The median age was 25years. Majority of the patients were males (94%). The involved facial region appeared to influence the need for operative management and this reached statistical significance (Chi-square 22.703, P<.001). GSW injuries to LF were 2.94 times more likely to require operative intervention than injuries to the MF (RR=2.94, 95% CI=1.625-5.327). Injuries of the UF were 2 times more likely to require operative intervention than injuries of the MF (RR=2.03, 95% CI 1.023-4.008). Injuries to the UF were more likely to be associated with intracranial injuries (Chi-square=20.522, P<.001). In patients with facial GSW injuries, there is an association between injury location and the need for operative intervention. Injuries to the LF were most likely to require surgical intervention followed by the UF and MF, respectively.

Team Performance in High-Fidelity Simulations of Postpartum Hemorrhage Management [A336

INTRODUCTION: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and presents care teams with unique, time-sensitive challenges. Simulation provides a way to evaluate team performance with no risk to patients. Identification of common errors is important to target training and optimize outcomes. METHODS: High-fidelity simulation exercises were conducted at a national obstetric critical care conference between 2014 and 2019. A simulated case of a PPH preceded by placental abruption was performed by multidisciplinary teams using high-fidelity simulators. Team performance was evaluated using a standardized checklist of key actions, and each item was scored as “not done”, “poorly done”, or “well done”. Descriptive statistics were then compiled for analysis. The study was reviewed and determined to be exempt by the hospital institutional review board. RESULTS: Complete performance data was available for 155 teams. Appropriate diagnosis of etiology of the hemorrhage (uterine atony) and timely recognition of the need for operative management was well done by most teams (91% and 92.3%, respectively). However, a significant number of teams demonstrated poor performance regarding inspection for lacerations (34.2%) and checking for retained products of conception (38.1%). Additionally, poor performance was identified for timely initiation of blood transfusion (11.6%) and activation of a massive transfusion protocol (20.6%). CONCLUSION: Thorough assessment of time-sensitive care interventions revealed specific deficits in team performance of PPH. High-fidelity simulation provides opportunities for exposure to obstetric emergency and may help to both target and determine the effectiveness of trainings designed to address these identified performance gaps.

Simulation model of the car service inventory management system: input parameters

The paper describes the problem of car service inventory management and the need for operational management of their quantity. The purpose and use of simulation modeling for solving the problem of order management are indicated. A model of inventory management at car service enterprises is constructed using simulation methods. The components of the simulation model are determined, which include controlled managed parameters, controlled unmanaged parameters, uncontrolled parameters and output indicators. For each component a characteristic is given. The input parameters of simulation modeling are presented, including the volumes of orders for car service repair parts. The input parameters used for the simulation are based on actual car dealership orders. Based on the data obtained, calculations of the arithmetic mean, standard deviation, median, coefficient of variation, asymmetry and kurtosis are performed. A distribution histogram is constructed for individual parameters. The results of the study reveal an exponential distribution of the volume of orders.

672 OESOPHAGOGASTRIC ANASTOMOTIC LEAK IN THE THORAX TREATED WITH COVERED METAL STENTS: SAFE AND HIGHLY SUCCESSFUL

Abstract Anastomotic leak (AL) develops in 5–22% of cases following oesophagectomy, and results in additional morbidity, and reduction in overall survival. The management of AL has evolved significantly with advances in endoscopic therapies. Covered cylindrical metal stents have been increasingly used, and insertion techniques have improved over time. We aimed to investigate the effectiveness and safety of modern metal stents in the management of AL. Methods All patients who underwent oesophagectomy with thoracic anastomosis between 2006–2020, and subsequently developed AL were retrospectively identified. Initially, treatment details and patient outcomes were assessed for the subgroup of patients where the AL was initially managed using a stent. In all cases, these were cylindrical covered metal stents. Those patients that progressed to surgery after treatment with a stent were then excluded, with the remainder compared to the subgroup of patients that underwent conservative (i.e., non-interventional) treatment for AL. Results Of 63 patients with AL, primary management was with stents in 32 (57%). Technical success was achieved in all stenting procedures, although three patients (9%) developed complications (stent migration). After stenting, six cases (19%) subsequently required escalation to operative management (thoracotomy). The remainder (N = 23) were then compared to those managed conservatively (N = 26) and were found to have a significantly longer length of hospital stay (median: 37 vs. 20 days, p = 0.003). The AL healing rate was 96% in both groups (p = 1.000); one conservatively managed patient died before healing, and one stented patient refused further treatment. Conclusion Endoscopic treatment of oesophageal AL with cylindrical covered metal stents is safe, with a high technical success rate, and low rates of stent-related morbidity. Treatment with stents also avoids the need for operative management including oesophageal disconnection in the majority of cases, whilst leading to successful healing of the AL. However, treatment with stents does significantly increase hospital stay over conservative management, particularly where multiple procedures are required.

A surgeon's predicament: Clinical predictors of surgery and mortality in neutropenic enterocolitis

BackgroundNeutropenic enterocolitis is uncommon but potentially life-threatening, with the cornerstone of treatment being medical management (MM), and surgical intervention reserved for clinical deterioration or bowel perforation. We hypothesized that the Shock Index Pediatric Age-Adjusted (SIPA) is elevated in patients who are at greatest risk for surgical intervention and mortality. We also sought to identify computed tomography (CT) findings associated with surgical intervention and mortality. MethodsA single-center cancer registry was reviewed for neutropenic enterocolitis patients from 2006 -2018. Survival models compared patients with normal versus elevated SIPA throughout their hospitalizations for the time to surgical management (SM), as well as in-hospital mortality. ResultsSeventy-four patients with neutropenic enterocolitis were identified; 7 underwent surgery. In-hospital mortality was 12% in MM and 29% in SM; mortality among patients with elevated SIPA was 4.7 times higher compared to those with normal SIPA (95% CI: 1.1, 19.83, p = 0.04). CT findings of bowel obstruction, pneumatosis, and a greater percentage of large bowel involvement were associated with surgical intervention (all ps < 0.05). ConclusionSelect pre-operative CT findings were associated with need for operative management. Elevated SIPA was associated with increased mortality. Elevated SIPA in pediatric cancer patients with neutropenic enterocolitis may help to identify those with more severe disease and expedite beneficial interventions.

Growth hormone replacement therapy: is it safe to use in children with asymptomatic pituitary lesions?

Small pituitary cysts are commonly discovered on pediatric brain magnetic resonance imagings (MRIs), particularly in patients with growth hormone deficiency (GHD). We examined the need for operative management in children with these masses as well as the effect of growth hormone replacement (GHR) on these lesions. This was a retrospective review of pituitary protocol MRIs conducted in children 0-19 at a single center between April 2010-November 2020. Sex, indication for initial MRI, volume, and whether surgery was performed was determined. Records were reviewed to determine whether GHD was present and treatment with GHR documented. For patients with subsequent MRIs, volume on most recent scan was calculated. Of the 101 children with cysts, 25 had laboratory-confirmed GHD and 76 did not. GHD patients had a higher mean age compared to no growth hormone deficiency (NGHD) cohort (11.2 and 8.4 years, respectively; p=0.02) and a larger proportion of males (p<0.001). The mean cyst volume on initial MRI was not significantly smaller in patientswith GHD (0.063±0.012cm3) vs. those without GHD (0.171±0.039cm3, p=0.11). Of the 21 GHD patients who received GHR and had follow-up MRIs, 10 had no change in pituitary cyst size, two had cysts that shrank, and seven disappeared. The remaining two cysts enlarged an average of 0.061±0.033cm3. Zero GHR recipients required surgical intervention. Small sellar cysts discovered incidentally on imaging in children are unlikely to require surgical intervention. GHR does not appear to significantly enlarge these pediatric pituitary lesions and is safe for use.

QS2: The Underreporting Of Traumatic Brain Injuries In Pediatric Craniomaxillofacial Trauma - A 20 Year Retrospective Cohort Study

Purpose:Despite clinical concerns associated with traumatic brain injuries (TBIs), they remain grossly underreported: 46% of TBIs in adult craniomaxillofacial (CMF) trauma patients remained unrecorded at discharge. This has not been studied in the pediatric CMF trauma population. Consequently, this is the first retrospective study to characterize concomitant pediatric TBI and CMF trauma patients, including incidence, presentation, documentation, and outcomes. The authors hypothesize that TBI in pediatric CMF trauma is associated with worse prognosis and remains under-recorded.Methods:An IRB-approved retrospective cohort study was performed to identify all pediatric patients presenting with CMF fractures at a high volume, tertiary trauma center between January 1st, 1990 to December 31st, 2010. Patients were included if they were (1) age younger than 15 years and (2) confirmed presence of CMF injury by means of imaging, radiology report, and physical examination. Patient charts were reviewed for demographic information, dentition stage, CMF fracture patterns, mechanism of injury, presentation, need for operative management, length of stay, and mortality at 2 years. Charts were reviewed to identify concomitant TBIs, defined as intracranial injury, cerebral hemorrhage, brain concussion, epilepsy or seizures (post-traumatic), and traumatic brain injury (documented). Data was analyzed using two-tailed Student’s t-tests and chi square analysis. Point-biserial correlation coefficients were calculated between a continuous and dichotomous variable; Pearson correlation coefficients were calculated between continuous variables. A P value ≤ 0.05 was considered statistically significant.Results:Of the 2966 pediatric CMF trauma patients identified and included for analysis (mean age of 7 +/- 4.7 years old, predominantly white, 59.8%, and male, 64.0%), 809 had concomitant TBI (frequency of 27.3%). Only 13 of the 809 TBI cases were documented in charts (1.6%). Concomitant TBI with CMF trauma patients were more likely to be male (69.1% vs 62%, P < 0.05), and be caused by blunt injury (98.9% vs. 95.5%, P < 0.05), compared to CMF trauma patients without TBI. TBI patients had a higher mortality rate at two years (8.0% vs 4.8%, P < 0.05). Mortality at two years, length of stay in hospital, and time to follow up significantly increased from mild to severe TBIs. Concomitant TBI and CMF trauma patients were also more likely to present with skull & upper third fractures than CMF trauma without TBI (81.8% vs 61.1%, P < 0.05).Conclusion:In this 20-year retrospective review, concomitant TBI injuries were present in a significant number of pediatric CMF trauma cases (27.3%) but was not documented for most cases. Given the importance of initial management and long-term care in TBI patients, it is critical for clinicians to remain vigilant for and manage TBIs in pediatric CMF trauma patients in collaboration with appropriate neurology and/or neurosurgery teams. Future prospective studies are necessary to better characterize TBI patient injury patterns and outcomes to generate practice guiding recommendations for this patient population.

Is the modified Gartland classification system important in deciding the need for operative management of supracondylar humerus fractures?

PurposeThis study examined levels of agreement between paediatric orthopaedic surgeons in the need for operative management of extension-type supracondylar humerus fractures.MethodsThis was the second phase of a two-part study. De-identified baseline anteroposterior and lateral elbow radiographs from 60 paediatric patients with extension-type supracondylar humerus fractures were compiled. After classifying each fracture according to Gartland classification guidelines, radiographs were randomized, and surgeons indicated whether they would use operative or non-operative management to treat each fracture. Kappa statistics using pairwise comparisons were calculated to determine agreement levels.ResultsIn total, 11 international surgeons participated, and 10/11 completed both survey rounds. The overall weighted interobserver agreement was moderate (0.530, 95%CI [0.215,0.854]) while overall weighted intraobserver agreement was substantial (0.740, 95%CI [0.513,0.963]). The largest variability in preferred treatment methods between surgeons was observed for type IIA fractures, with 6/11 preferring non-operative and 5/11 preferring operative management. The largest individual surgeon variability was observed for type IIA fractures, with 8/11 showing variability (defined by not having made the same decision for at least 90% of the cases) in choosing whether to operate.ConclusionsOur findings suggest moderate interobserver, and substantial intraobserver agreement in treatment decision making. The largest disagreements between surgeons were observed for type IIA and IIB fractures and treatment decisions did not follow expected trends based on surgeons’ preferred treatment methods for each fracture type. This suggests differences in treatment approaches between surgeons in the management of type IIA fractures and highlights the role of other variables that underlie differences between surgeons’ treatment preferences.Level of evidenceIII

Decision-making in pediatric blunt solid organ injury: A deep learning approach to predict massive transfusion, need for operative management, and mortality risk

BackgroundThe principal triggers for intervention in the setting of pediatric blunt solid organ injury (BSOI) are declining hemoglobin values and hemodynamic instability. The clinical management of BSOI is, however, complex. We therefore hypothesized that state-of-art machine learning (computer-based) algorithms could be leveraged to discover new combinations of clinical variables that might herald the need for an escalation in care. We developed algorithms to predict the need for massive transfusion (MT), failure of non-operative management (NOM), mortality, and successful non-operative management without intervention, all within 4 hours of emergency department (ED) presentation. MethodsChildren (≤18 years) who sustained a BSOI (liver, spleen, and/or kidney) between 2009 and 2018 were identified in the trauma registry at a pediatric level 1 trauma center. Deep learning models were developed using clinical values [vital signs, shock index-pediatric adjusted (SIPA), organ injured, and blood products received], laboratory results [hemoglobin, base deficit, INR, lactate, thromboelastography (TEG)], and imaging findings [focused assessment with sonography in trauma (FAST) and grade of injury on computed tomography scan] from pre-hospital to ED settings for prediction of MT, failure of NOM, mortality, and successful NOM without intervention. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) were used to evaluate each model's performance. ResultsA total of 477 patients were included, of which 5.7% required MT (27/477), 7.2% failed NOM (34/477), 4.4% died (21/477), and 89.1% had successful NOM (425/477). The accuracy of the models in the validation set was as follows: MT (90.5%), failure of NOM (83.8%), mortality (91.9%), and successful NOM without intervention (90.3%). Serial vital signs, the grade of organ injury, hemoglobin, and positive FAST had low correlations with outcomes. ConclusionDeep learning-based models using a combination of clinical, laboratory and radiographic features can predict the need for emergent intervention (MT, angioembolization, or operative management) and mortality with high accuracy and sensitivity using data available in the first 4 hours of admission. Further research is needed to externally validate and determine the feasibility of prospectively applying this framework to improve care and outcomes. Level of EvidenceIII Study TypeRetrospective comparative study (Prognosis/Care Management).

SOCIETY AND THE STATE: INFORMATION AND COMMUNICATION TECHNOLOGIES TO OVERCOME THE «CRISIS OF TRUST» IN THE CONTEXT OF THE PANDEMIC

The article analyzes the process of interaction between the state and society in the context of the development of digital technologies against the background of an emergency situation related to the spread of coronavirus. The article reveals the causes of the crisis of trust in the interaction of social and political institutions that is characteristic of modern society. The most important role of information and communication technologies in the conditions associated with the need for operational management of information flows to prevent political destabilization is shown. The author substantiates the idea that in the face of the threat of a pandemic, society is ready to review some of the guidelines related to the protection of civil liberties and accept new restrictions in exchange for a more effective state policy to ensure the safety of life and health.

Validity of the Best Practice Tariff in paediatric major trauma: A retrospective cohort study from a level 1 children's major trauma centre

IntroductionThe Best Practice Tariff (BPT) in major trauma awards Major Trauma Centres (MTCs) a financial incentive when predefined standards of care are met. However, no tailored criteria exist with regards to the reimbursement policy in paediatric major trauma. In this study, we aim to examine the utility of the paediatric Major Trauma BPT and identify predictors of additional resource utilisation. Materials and methodsThis cohort study encompassed all paediatric major trauma calls (N = 682) presenting to a designated combined adult and paediatric MTC between July 2014 and June 2017. Patient demographics, admission pattern, injury parameters, length of stay (LOS) and the need for operative management were collected. Patients approved for the BPT uplift payment (BPT group) were compared with the cohort of children not qualifying (non-BPT group). ResultsOverall, less than a quarter (23.2%) of the trauma population qualified for the BPT. The proportion of patients requiring operative intervention and CT scanning in the BPT group was significantly higher (p<0.001). These children also attained a higher ISS (median, 13.5 vs. 0, p <0.001) and required longer hospitalisation. Following a Receiver Operator Characteristic (ROC) curve analysis, a cut off ISS score > 8 demonstrated an excellent predictive value in identifying children qualifying for BPT (true positive and false positive rates: 90% and 10.7%). However, a subgroup analysis including the more severely injured children (ISS >8) not qualifying for the uplift payment revealed that equally substantial resource went into their management - 42.9% needed surgical intervention and 57.1% a CT scan. DiscussionThis study demonstrated that BPT in paediatric major trauma is a valuable reimbursement; however, our findings also unveiled a cohort deemed ineligible for BPT despite the high costs accrued. Re-evaluation of the remuneration criteria of paediatric major trauma networks with an alternative, more inclusive reimbursement policy is needed.

Impact of unoperated adolescent idiopathic scoliosis in adulthood: a 10-year analysis.

Retrospective, cross-sectional. To evaluate the impact of unoperated adolescent idiopathic scoliosis (AIS) in adulthood on pain, quality of life, and need for operative management. Long-term studies of AIS in adulthood demonstrate most patients function well, though some have increased disability. The Oswestry Disability Index (ODI) and SRS-22r are validated questionnaires for assessing back disability and quality of life. Correlation of these questionnaires to patient outcomes and necessity for surgery have not been fully defined. Unoperated adults with AIS seen in a tertiary deformity clinic from 2008-2018 were identified. Variables included demographics, comorbidities, family history, curve size/location, pain score, ODI, SRS-22r, and previous treatment. ODI and SRS-22r scores were analyzed across three age groups: 20-39, 40-59, and ≥ 60. 275 eligible patients were identified and 255 (93%) patients had an ODI and/or SRS-22r score. ODI scores (220 patients) had a positive correlation with age, BMI, and curve size (p < .001). SRS-22r (204 patients) pain score was worse in all age-gender-matched domains (p < .05). Of the 255 patients in the study, 10% underwent surgery after presentation. In 118 patients with surgical-size curves (thoracic ≥ 50°; thoracolumbar ≥ 40°), no difference was seen in age or curve size between surgical and non-surgical patients; however, ODI and SRS-22r scores (excluding mental health) were significantly worse in surgical patients (p ≤ .01). Patients with AIS have SRS-22r scores that are lower than age-gender-matched controls in most domains. ODI had a positive linear correlation with age, body mass index, and curve size. Only 10% of adults with surgical-size curves evaluated for scoliosis elected to undergo surgery. Patients treated surgically reported worse preoperative quality-of-life scores than their non-surgical counterparts. These results can help healthcare providers when counseling patients and families concerning management options. III.

Over-the-scope clip management of non-acute, full-thickness gastrointestinal defects.

Endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy, as it avoids the morbidity of surgery. We have previously described the short-term outcomes of over-the-scope clip management of 22 patients with non-acute FTGID. This study updates our prior findings with a larger sample size and longer follow-up period. A retrospective analysis of prospectively collected data was conducted. All patients undergoing over-the-scope clip management of FTGID between 2013 and 2019 were identified. Acute perforations immediately managed and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete FTGID closure. We identified 92 patients with 117 FTGID (65 fistulae and 52 leaks); 27.2% had more than one FTGID managed simultaneously. The OTSC device (Ovesco Endoscopy, Tubingen, Germany) was utilized in all cases. Additional closure attempts were required in 22.2% of defects. With a median follow-up period of 5.5months, overall defect closure success rate was 66.1% (55.0% fistulae vs. 79.6% leaks, p = 0.007). There were four mortalities from causes unrelated to the FTGID. Only 14.9% of patients with FTGID underwent operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention. Over-the-scope clip management of FTGID represents a safe alternative to potentially morbid operative intervention. When strictly defining success as complete closure of all FTGID, endoscopy was successful in 64.4% of patients with only a small minority of patients ultimately requiring surgery.

Should Endometrial Biopsy be Used for Diagnosing Polyps? [33E

INTRODUCTION: Abnormal uterine bleeding (AUB) accounts for more than 70% of visits to gynecologists. American College of Obstetricians and Gynecologists (ACOG) recommends endometrial sampling for women above age 45. This is done in clinic with an endometrial biopsy. One known limitation of the biopsy is limited sampling as only 4% of the cavity is sampled. Past studies demonstrate limitations in using endometrial biopsy to diagnose polyps, with biopsy missing 15/16 polyps. Our study sought to evaluate when the biopsy diagnoses a polyp. Is the specificity sufficient to proceed to the operating room, or are there other imaging or patient characteristics that can guide management? METHODS: This was a retrospective cohort study that identified patients with AUB who underwent endometrial biopsy and a confirmatory procedure of hysteroscopy or hysterectomy at the University of Colorado Hospital from 2005-2010. Patients were identified as having an endometrial biopsy, hysterectomy, or hysteroscopy with CPT codes, and ICD9 codes were used to eliminate women without AUB. RESULTS: A total of 216 charts were reviewed with mean age of 44 and BMI of 30.49 kg/m^2. The specificity of using endometrial biopsy to diagnose polyps was 87.2%, and we confirmed poor sensitivity at 30%. Vaginal ultrasound had a higher specificity at 94%. Logistic regression analyses will be utilized to identify patient factors, patient bleeding profile, and procedures to determine how best to triage patients for operative management of endometrial polyps. CONCLUSION: Endometrial biopsy should not be the only factor in determining a patient's need for operative management of AUB associated with polyps.

Pediatric Lawnmower Injuries and Strategies for Prevention

Lawnmower injuries remain a preventable cause of serious morbidity and even mortality in children. We aimed to characterize lawnmower injuries in children and to describe reported mechanisms through a review of the literature to better understand these injuries and their prevention. The Embase and MEDLINE databases were queried for studies pertaining to pediatric lawnmower injuries, along with manual searching of references of included studies and Google Scholar searches. Reviews and case reports were excluded. Studies relating to lawnmower injuries were broadly included to ensure capture of the relevant studies. Studies with both adult and pediatric data were included if pediatric data were granular and available for separate analysis. Thirteen studies met inclusion criteria: 8 single-center series and 5 national database studies. Age of injury was bimodal with peak frequencies at ages 3 and 16 years. National studies estimated a mean of 11.2 injuries per 100,000 children, with 5% to 8% of patients hospitalized. Analysis of both single-center series and national database studies revealed 3 major mechanisms of injury: blade injuries, projectile injuries, and burn injuries. Blade injuries resulted in higher morbidity, with a greater need for operative management, amputation, and longer length of hospitalization. Similarly, rider mowers posed a greater injury risk than push mowers. This systematic review of lawnmower injuries in children identified patterns and mechanisms of injuries across the literature that may serve to educate parents, policy-makers, and health-care providers as well as provide data to develop and improve prevention strategies.