Objectives: Chronic stressors are associated with cardiometabolic health conditions and disparities. Mechanisms linking stressors and health remain poorly understood. Methods: Two cohort studies (Cardiac Rehabilitation And The Experience [CREATE] and Tracking Risk Identification for Adult Diabetes [TRIAD]) with harmonized variables were used to examine relationships between six types of chronic stressors in adulthood and Hypothalamic-Pituitary-Adrenal (HPA) axis dysregulation, as indicated by blunted diurnal cortisol slopes, which are stress-sensitive biomarkers implicated in cardiometabolic health (merged N = 213, mean age 61, 18% Black). A secondary aim was to explore whether these chronic stressors accounted for Black-White disparities in HPA axis regulation. Results: Some chronic stressors were linked to HPA axis dysregulation, with recent stressors most salient (b = 0.00353, SE = 0.00133, p = .008). Black-White disparities in HPA axis regulation persisted after controlling for racial differences in chronic stressors, which reduced the disparity 11.46%. Discussion: Chronic stressors in adulthood may increase risk for HPA axis dysregulation and associated cardiometabolic health outcomes but may not be a key factor in racial disparities.

Kersey, Alexander J. MD; Fox, Charles J. MD, FACS; White, Paul W. MD, FACS; Lauria, Alexis L. MD; Burmeister, David M. PhD; Rodriguez, Carlos MD, FACS; White, Christopher E. MD, FACS; White, Joseph M. MD, FACS Author Information

Suprascapular neuropathy is a well-known cause of shoulder pain and dysfunction. Common locations for suprascapular nerve (SSN) entrapment are the suprascapular notch and the spinoglenoid notch. Multiple authors have described both open and arthroscopic approaches for SSN decompression; however, to our knowledge, there is no description of decompression of the SSN at the suprascapular notch using a hybrid endoscopic approach to maximize the advantages of both. The patient was a 27-year-old, white male laborer, who presented with a 6-month history of left shoulder pain and decreased function without a history of trauma. A standard course of conservative treatment including nonsteroidal anti-inflammatory drugs, activity modification, and physical therapy was attempted but failed to result in symptomatic improvement. Magnetic resonance imaging and electromyography were subsequently ordered and demonstrated a subacute muscle denervation pattern indicating the SSN as the most probable site of compression. Given the patient's clinical examination, failure of nonoperative management, age, and his activity level, he was offered surgical intervention. The technique described in this report utilizes a novel, safe, effective, and facile approach for the release of the transverse scapular ligament. We present our hybrid endoscopic technique along with a case report demonstrating a good patient outcome to emphasize the successful application of our technique following appropriate utilization of history, physical examination, and diagnostic tests when deciding to operatively treat a patient with isolated suprascapular neuropathy.

OBJECTIVES:To describe in detail both the proximity and location of the subclavian vessels relative to both the right and left clavicle. This will give surgeons a more precise knowledge of safe and dangerous areas for screw placement during operative stabilization of clavicle fractures.METHODS:A radiology storage database was reviewed to obtain a total sample of 103 clavicles with no evidence of periclavicular pathology. Each clavicle was divided along its length into 13 specific points of measurement. At each point, the distance and angular position between the clavicle and each subclavian vessel were measured.RESULTS:The mean distance of the subclavian artery was greater than 10 mm at all positions. At the most medial point of the clavicle, the right subclavian artery was on average 1 cm closer to the clavicle than on the left. From medial to lateral, in the sagittal plane, the position of the subclavian artery transitions obliquely across the clavicle from a 2 to 6 o'clock position. The mean distance to the subclavian vein is less than 10 mm along the medial half of the clavicle on both sides of the body. In these areas, the position of the subclavian vein to the clavicle transitions from the 3 to 5 o'clock positions from medial to the mid-point of the clavicle.CONCLUSIONS:The subclavian vein is the vascular structure at highest risk during clavicle fracture fixation. The major area of danger in our study is the medial clavicle with distance being less than 1 centimeter over the entire medial half of the clavicle on both right and left. In this danger area, the subclavian vein courses from 3 to 5 o'clock positions. The subclavian artery is more distant and relatively safer but is closer at the right medial clavicle than the left.

OBJECTIVE:To report a case series of three patients with septic arthritis of the acromioclavicular joint and a review of the literature for this condition. Additionally, we developed an algorithm for diagnosing and treating septic arthritis of the acromioclavicular joint.METHODS:A retrospective review of patients treated at our institution for septic arthritis of the acromioclavicular joint during the collection period was performed and three cases were identified. A review of the English literature on this rare condition was also performed with only 28 cases being identified.RESULTS:A series of three consecutive patients were treated for septic acromioclavicular arthritis with resolution of the infection. Two patients underwent open surgical debridement and one underwent aspiration. All patients were treated with a minimum of six weeks of tailored intravenous antibiotic therapy.CONCLUSION:Septic arthritis of the acromioclavicular joint can be difficult to diagnose and requires a high index of suspicion. Surgical debridement, open or arthroscopic, with tailored antibiotic therapy is an effective means for the management of septic arthritis of the acromioclavicular joint. In patients who are unable to have surgical debridement, aspiration and tailored antibiotics have been shown to be effective.

Edwards, Mary J. MD, COL, USA, FACS; White, Christopher E. MD, COL, USA, FACS; Remick, Kyle N. MD, COL, USA, FACS; Edwards, Kurt D. MD, COL, USA, FACS; Gross, Kirby R. MD, COL, USA, FACS Author Information

Background: Burn and trauma patients present a clinical challenge due to metabolic derangements and hypermetabolism that result in a prolonged catabolic state with impaired healing and secondary complications, including ventilator dependence. Previous work has shown that circulating levels of growth hormone (GH) are predictive of mortality in critically ill adults, but few studies have examined the prognostic potential of GH levels in adult trauma patients.Methods: To investigate the utility of GH and other endocrine responses in the prediction of outcomes, we conducted a prospective, observational study of adult burn and trauma patients. We evaluated the serum concentration of GH, insulinlike growth factor 1 (IGF-1), IGF binding protein 3 (IGFBP-3), and glucagon-like peptide-2 (GLP-2) weekly for up to 6 weeks in 36 adult burn and trauma patients admitted between 2010 and 2013.Results: Non-survivors had significantly higher levels of GH and GLP-2 on admission than survivors.Discussion: This study demonstrates that GH has potential as a predictor of mortality in critically ill trauma and burn patients. Future studies will focus on not only the role of GH, but also GLP-2, which was shown to correlate with mortality in this study with a goal of offering early, targeted therapeutic interventions aimed at decreasing mortality in the critically injured.Conclusions: GH and GLP-2 may have clinical utility for outcome prediction in adult trauma patients.

INTRODUCTION:Damage control laparotomy (DCL) in an austere environment is an evolving surgical modality.METHODS:A retrospective evaluation of all patients surviving 24 hours who underwent a laparotomy from 2002 to 2011 in Iraq and Afghanistan was performed. DCL was defined as a patient undergoing laparotomy at two distinct North American Treaty Organization (NATO) Role 2 or 3 medical treatment facilities (MTFs); a NATO Roles 2 and 3 MTFs, and/or having the International Classification of Diseases, 9th Revision, Clinical Modification procedure code 54.12, for reopening of recent laparotomy site. Definitive laparotomy (DL) was defined as patients undergoing one operative procedure at one NATO Role 2 or 3 MTF. Demographic data including injury severity scores, hematological transfusion, mortality, intraperitoneal or retroperitoneal operative interventions, and complications were compared.RESULTS:DCL composed of 26.5% (n = 331) of all 1,248 laparotomies performed between March 2002 and September 2011. Total intra-abdominal, acute respiratory distress syndrome, and thromboembolic complications for DCL versus DL were 8.5% and 5.6% (p = 0.07), 2.1% and 0.8% (p = 0.06), and 1.5% and 0.7% (p = 0.17), respectively. Theater discharge mortality from DCL and DL were 1.5% (n = 5), and 1.4% (n = 13) (p = 0.90), respectively.CONCLUSIONS:In conclusion, excluding deaths with the first 24 hours, DCL and DL had comparable mortality and complication rates at NATO Roles 2 and 3 MTFs.

Physical violence is a frequent occurrence in acute community psychiatry units worldwide. Violent acts by patients cause many direct injuries and significantly degrade quality of care. The most accurate tools for predicting near-term violence on acute units rely on current clinical features rather than demographic risk factors. The efficacy of risk assessment strategies to lower incidence of violence on acute units is unknown. A range of behavioral and psychopharmacologic treatments have been shown to reduce violence among psychiatric inpatients.

Background: Appropriate indications for resuscitative thoracotomy (RT) in an austere environment continue to evolve; the aim of this study was to determine survival and to analyze demographics of survivors within U.S. military personnel undergoing RT. Methods: A retrospective review was performed of all U.S. soldiers who underwent thoracotomy in theater during Operation Iraqi Freedom and Operation Enduring Freedom. After individualized review, patients in extremis or who lost pulses and had their thoracotomy performed within 10 minutes of arrival to the emergency department were included. The primary outcome was survival at final hospital discharge, and secondary outcomes included demographics associated with survival. Results: Between January 2003 and May 2010, 81 U.S. military personnel met inclusion criteria for RT in theater. As low as 6.7% (3/45) of patients receiving prehospital cardiopulmonary resuscitation were alive at final hospital discharge. Survival from RT after explosive/blast injury, penetrating (gunshot wound), and blunt trauma were 16.3% (8/49), 0% (0/28), and 0% (0/4), respectively. Patients with primary explosive/blast extremity trauma undergoing RT had a survival of 27.3% (6/22). Higher initial oxygen saturations, larger volume of crystalloids and blood products infused, and higher extremity abbreviated injury score were all associated with survival. Conclusions: Combat casualties who present pulseless or in extremis who were injured as a result of an explosive/blast injury mechanism resulting in a primary extremity injury may have a survival benefit from undergoing a RT in an austere environment.

Objectives: Postsplenectomy vaccination (PSV) in an austere environment to minimize overwhelming postsplenectomy infection is challenging. We evaluated the clinical impact of a March 2008 clinical practice guideline (CPG) dictating immediate PSV at North American Treaty Organization Role 3 medical treatment facilities and subsequent complications. Methods: Utilizing U.S. military medical databases, we characterized all U.S. patients with a splenic injury from November 2002 to January 2012 by their surgical management: laparotomy with splenectomy (LWS), laparotomy without splenectomy, or nonoperative management. Relevant data including demographics, vaccinations, and documented bacterial and fungal isolates were obtained. Results: LWS comprised 63.6% of the 409 patients with a splenic injury from 2002 to 2012. The implementation of the PSV CPG improved overall vaccination compliance from 48.9% pre-PSV CPG to 86.9% post-PSV CPG (p < 0.01). It was found that 1.3% (2/159) of completely vaccinated LWS patients compared with 0% (0/101) of the incompletely vaccinated LWS patients had Streptococcus pneumoniae isolates in 391.0 and 251.4 follow-up years, respectively (p = 0.52). No Neisseria meningitidis or Haemophilus influenzae isolates were identified. Conclusions: PSV CPG implementation improved theater vaccination without increasing the incidence of encapsulated organisms.

BACKGROUND Many military and civilian centers have shifted to a damage-control resuscitation approach, focused on providing oxygen-carrying capacity while simultaneously mitigating coagulopathy with a balanced ratio of platelets and plasma to red blood cells. It is unclear to what degree this strategy is used during burn or soft tissue excision. Here, we characterized blood product transfusion during burn and soft tissue surgery and reviewed the published literature regarding intraoperative coagulation changes. We hypothesized that blood product resuscitation during burn and soft tissue excision is not hemostatic and would be insufficient to address hemorrhage-induced coagulopathy. METHODS Consented adult patients were enrolled into an institutional review board–approved prospective observational study. Number, component type, volume, and age of the blood products transfused were recorded during burn excision/grafting or soft tissue debridement. Component bags (packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate) were collected, and the remaining sample was harvested from the bag and tubing. Aliquots of 1/1,000th the original volume of each blood product were obtained and combined, producing an amalgam sample containing the same ratio of product transfused. Platelet count, rotational thromboelastometry, and impedance aggregometry were measured. Significance was set at p < 0.05. RESULTS Amalgamated transfusate samples produced abnormally weak clots (p ⩽ 0.001) particularly if they did not contain platelets. Clot strength (48.8 [2.6] mm; reference range, 49–71 mm) for platelet-containing amalgams was below the lower limit of the reference range despite platelet–red blood cell ratios greater than 1:1. Platelet aggregation was abnormally low; transfused platelets were functionally inferior to native platelets. CONCLUSION Our study and focused review demonstrate that further work is needed to fully understand the needs of patients undergoing tissue excision. The three studies reviewed and the results of our observational work suggest that coagulopathy and thrombocytopenia may contribute to intraoperative hemorrhage. Blood product resuscitation during burn and soft tissue excision is not hemostatic. LEVEL OF EVIDENCE Epidemiologic study, level V.

Given the changing epidemiology of infecting pathogens in combat casualties, we evaluated bacteria and fungi in acute traumatic wounds from Afghanistan. From January 2013 to February 2014, 14 mangled lower extremities from 10 explosive-device injured casualties were swabbed for culture at Role 3 facilities. Bacteria were recovered from all patients on the date of injury. Pathogens recovered during routine patient care were recorded. The median injury severity score was 29, median initial Role 3/4 blood product support was 32 units, and median evacuation time was 42 minutes to first surgical care. Gram-positive bacteria were found in some wounds but not methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus. Most wounds were colonized with low-virulence, environmental gram-negative bacteria, and not recovered again during therapy, reflecting wound contamination. Only one wound had the same bacteria (E. cloacae) throughout care at the Role 3, 4, and 5 facilities. Three cultures from two patients had multidrug-resistant bacteria (E. cloacae, E. coli), all detected at Role 5 facilities. Molds were not detected at Role 3, whereas one patient had a mold at Role 4 and 5. Mangled lower extremity injuries have a high contamination rate with environmental organisms, which are not typically associated with infections during the course of the patient's care.

BACKGROUND The civilian literature has expanded the indications for selective nonoperative management (SNOM) for abdominal trauma to minimize morbidity from nontherapeutic laparotomies (NTLs); however, this treatment modality remains controversial and rare in austere settings. This study aimed to quantify the percentage of NTL and incidence of failed SNOM performed in theater and to define each of their respective intra-abdominal–related morbidities. METHODS A retrospective evaluation of all patients who underwent a laparotomy from 2002 to 2011 during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) was performed for patients who survived a minimum of 24 hours. With the use of DRG International Classification of Diseases—9th Rev. procedure codes, a therapeutic laparotomy was defined by the presence of a defined intraperitoneal or retroperitoneal procedure; an NTL was defined by the absence of a defined intraperitoneal or retroperitoneal procedure. Second, patients transferred from North American Treaty Organization Role II to Role III medical treatment facilities to be operated on were deemed failed SNOM. Finally, intra-abdominal complications and mortality were identified for patients undergoing therapeutic laparotomy, NTL, and failed SNOM. RESULTS Blunt, burn, and penetrating injuries accounted for 38.5% (n = 490), 1.1% (n = 14), and 60.4% (n = 769) of all laparotomies in the OEF and OIF, respectively. Thirty-two percent of all laparotomies performed during the OEF and OIF campaigns were NTL; specifically, the NTL rates in OEF and OIF were 38.2% and 28.6%, respectively. In addition, 31.6% and 32.2% of all penetrating and blunt injury mechanisms resulted in an NTL, respectively. The percentage of all patients identified as failing SNOM was 7.5% (n = 95). The early intra-abdominal complication rate for failed SNOM and for all patients undergoing NTL was 2.1% and 1.7%, respectively. CONCLUSION The OIF and OEF combined NTL rate was 32.1%, with an associated 1.7% intra-abdominal early complication rate. The infrequent application of SNOM in a deployed military environment is likely secondary to unpredictable fragmentation trajectories and related blast injury patterns, limited medical resources including computed tomography, and a complex aeromedical evacuation system preventing serial observation. LEVEL OF EVIDENCE Epidemiologic study, level IV.

Introduction: Historically, mucormycosis infections have been associated with high mortality. The purpose of this study was to determine the incidence, associated mortality, and management strategies of mucormycosis in a major burn center.Methods: A retrospective review was performed via obtaining all patients with mucormycosis admitted from January 2003 to November 2009 at our adult burn center was performed obtaining demographic data relevant to fungal burn wound infection or colonization.Results: The incidence of mucormycosis at our facility was 4.9 per 1000 admissions; specifically, 11 military casualties and one civilian were diagnosed with mucormycosis. The median percentage Total Body Surface Area (TBSA) burned, 11 patients, or open wound, one patient, was 60 (IQR, 54.1-80.0), and the incidence of documented inhalation injury was 66.7% (8 of 12). Ten patients had surgical amputations. A median of eight days (IQR, 3.5-74.5) elapsed from diagnosis of mucormycosis until death in the 11 patients who expired. The overall mortality was 92%; however, autopsy attributed mucormycosis mortality was 54.5% (6 of 11) with all six patients having invasive mucormycosis.Conclusion: Aggressive surgical intervention should be undertaken for invasive mucormycosis; additionally, implementation of standardized protocols for patients with large soft tissue injuries may mitigate mucormycosis superimposition. Published by Elsevier Ltd and ISBI

BACKGROUND:Selective nonoperative management of combat-related blunt splenic injury (BSI) is controversial. We evaluated the impact of the November 2008 blunt abdominal trauma clinical practice guideline that permitted selective nonoperative management of some patients with radiological suggestion of hemoperitoneum on implementation of nonoperative management (NOM) of splenic injury in austere environments.METHODS:Retrospective evaluation of patients with splenic injuries from November 2002 through January 2012 in Iraq and Afghanistan was performed. International Classification of Diseases, 9th Revision, Clinical Modification procedure codes identified patients as laparotomy with splenectomy, or NOM. Delayed operative management had no operative intervention at earlier North American Treaty Organization (NATO) medical treatment facilities (MTFs), and had a definitive intervention at a latter NATO MTFs. Intra-abdominal complications and overall mortality were juxtaposed.RESULTS:A total of 433 patients had splenic injuries from 2002 to 2012. Initial NOM of BSI from 2002 to 2008 compared to 2009-2012 was 44.1% and 47.2%, respectively (p=0.75). Delayed operative management and NOM completion had intra-abdominal complication and mortality rates of 38.1% and 9.1% (p<0.01), and 6.3% and 8.1% (p=0.77).CONCLUSIONS:Despite high-energy explosive injuries, NATO Role II MTFs radiological constraints and limited medical resources, hemodynamically normal patients with BSI and low abdominal abbreviated injury scores underwent NOM in austere environments.

STUDY DESIGN A retrospective review of 930 combat casualties from March 2003 to September 2009 who received a massive transfusion. Mechanism was categorized as explosion (EXPL) (712), gunshot wound (GSW) (190), and blunt trauma (28). Cohorts were also categorized by fresh frozen plasma (FFP) to red blood cell (RBC) ratio: low, ≤1:1.5 and high, >1:1.5. Patient characteristics and in-hospital mortality rates were compared among groups. Propensity matching was used to control for confounding variables. RESULTS Cohorts were similar in demographics, admission vital signs, and laboratory values. Median injury severity score was higher in EXPL compared to GSW. High FFP:RBC ratio was associated with improved survival compared to low ratio in the EXPL group (p < 0.01). The GSW group had similar survival in the high and low FFP:RBC ratio groups (p = 0.06). After propensity matching, a high FFP:RBC ratio was associated with improved survival compared to low ratio in both the EXPL (p < 0.01) and GSW groups (p = 0.05). CONCLUSIONS High FFP:RBC ratios are associated with improved survival in combat casualties regardless of injury mechanism.