Authors:
Fabiana C Sanchez, Grant V Bochicchio, Leonardo J Diaz Gandica, Marco J Henriquez, Melissa Canas, Michael W Alchaer, Ricardo A Fonseca

Body of Abstract:
Background:
A substantial body of literature explores the impact of length of stay (LOS) on complications, infections, morbidity, and mortality. However, detailed analyses of specific intervals within LOS and their contributions to patient outcomes, particularly in the context of delayed discharge, remain limited.
Methods:
We conducted an analysis of our multidisciplinary, prospectively maintained trauma database, including all trauma patients with a delay in discharge from 2018 to 2023 at our Level 1 trauma center. Patients with discharge delays related to non-medical reasons and those with delays related to COVID-19 were excluded.
LOS was defined as the total hospital stay. LOS minus delay in discharge time (LOS – DDT) was defined as the duration from admission to when patients were medically ready for discharge ([Phase I]), and DDT was defined as the time from when patients were medically ready for discharge to their actual discharge ([Phase II]). Patients were stratified into two cohorts: those with delays due to infections (DDI) and those with delays due to non-infectious medical reasons (DDNI).
Results:
Among 160 patients with a delay in discharge, 15 (9.4%) were in the DDI group, and 145 (90.6%) were in the DDNI group. Patients in the DDNI group were more likely to be African American (31.7% vs. 0%, p=0.035). Compared to DDNI patients, those in the DDI group had significantly higher total LOS (17.4 days vs. 9.58 days, p<0.001), higher LOS - DDT (11 days vs. 6.18 days, p=0.008), and higher DDT (6.4 days vs. 3.4 days, p<0.001). In a multivariate analysis controlling for Injury Severity Score (ISS), female sex, Glasgow Coma Scale (GCS), and age, LOS - DDT was significantly associated with DDI patients, with an odds ratio (OR) of 1.133 (p=0.017). Conclusion: A higher LOS - DDT ([Phase I]) was associated with increased infection rates among trauma patients experiencing delayed discharge for medical reasons. Additionally, the presence of infection correlated with longer DDT ([Phase II]). These findings suggest the need for strategies to optimize hospital discharge processes and minimize prolonged hospital stays to reduce the risk of infections.

Authors:
Adianto Nugroho, Aditomo Widarso, Indah Jamtani, Rofi Y Saunat

Body of Abstract:
Introduction

Pancreatic fluid collection after distal pancreatectomy is common and can be managed conservatively. However, in some cases, it can lead to a devastating sequel, such as a burst abdomen.

Case Illustration

A 55-year-old male was consulted to the digestive surgery service with acute abdomen 24 hours after endoscopic drainage of pancreatic pseudocyst. The patient was diagnosed with cystadenoma of the pancreas tail, and the endoscopist internist successfully did endoscopic internal drainage of the cyst. However, one day after the procedure, the patient complained of severe abdominal pain accompanied by nausea, vomiting, and fever. His laboratory showed a marked leukocytosis, and a repeat abdominal CT scan showed a large amount of intraperitoneal air, which was a deliberate process of the endoscopic procedure. The decision to take the patient to surgery was made after 12 hours of conservative management failed. Upon exploration of the abdomen, we discovered pancreatic juice collection at the left paracolic gutter and pelvic floor. We performed a formal distal pancreatectomy, using a linear cutter, along with the spleen, and primary repair of the stomach. A large peritoneal drain was left at the peripancreatic space and another at the pelvic floor. The abdomen was cleansed with sterile saline and sutured closed. In the postoperative follow-up, pancreatic juice leakage through the peripancreatic drain was confirmed by amylase workup of the fluid. The pancreatic juice leaked through the abdominal incision as well, causing a burst abdomen by postoperative day 6. The patient had also developed an overwhelming post-splenectomy infection in the form of hospital-acquired pneumonia and was admitted to the ICU.
Meanwhile, pancreatic juice leakage was treated conservatively with optimal drainage through the peripancreatic drain, and a negative pressure wound therapy (NPWT) device was applied to treat the burst abdomen. The pathology examination of the specimen revealed a pancreatic pseudocyst with no signs of malignancy. We screened the patient for tuberculosis as another factor in his slow healing, and oral anti-tuberculosis (OAT) medicine was administered. Soon after the administration of OAT, the pancreatic juice drainage slowly reduced, and his abdominal wall defect showed progress. The patient recovered from OPSI, and his abdominal wall defect was healing well with VAC. He was discharged POD-30 for homecare with the VAC device still applied and was scheduled for abdominal wall closure within the next month.

Conclusion
Conservative management of pancreatic juice collection can be successful owing to detailed and comprehensive patient management. In endemic regions, tuberculosis should always be suspected in slow-recovering patients.

Authors:
Manuel Castillo-Angeles, Reza Askari, Saba Ilkhani, Tandis Soltani

Body of Abstract:
Introduction:
Complicated appendicitis, characterized by generalized peritonitis and abscess formation, serves as a valuable “surgical access proxy,” with outcomes independently influenced by the timing of presentation, irrespective of care quality. Studies using nationally representative data suggest that Black patients are more likely to present with complicated appendicitis compared to White patients. Urbanicity also shapes these outcomes, with higher rates of complicated appendicitis presentations in rural areas. This study examines how racial disparities are influenced by rural versus urban settings.
Methods:
We analyzed data from the Nationwide Inpatient Sample (NIS) from 1990 to 2021, focusing on appendicitis cases. Among 1,218,245 cases of appendicitis, 14.5% were classified as complicated, involving generalized peritonitis and abscess formation. Multivariate logistic regression models were used to assess the impact of rural versus urban settings and racial disparities on complicated appendicitis, adjusting for age, gender, comorbidities, and insurance status. Secondary analyses examined urbanicity by transfer status and geographic region.
Results:
As expected, complicated appendicitis was more prevalent in rural areas compared to urban settings (14.7% vs. 13.9%, p< 0.001), and Black patients had a higher probability of complications compared to White patients (White: 14.8% [95% CI: 14.7–14.9], Black: 17.3% [95% CI: 17.1–17.6]). Urban areas exhibited significant racial disparities, with Black patients facing higher odds of complications compared to White patients (aOR = 1.05, 95% CI: 1.02–1.08, p = 0.001), while no significant racial disparities were observed in rural areas (aOR = 1.08, 95% CI: 0.96–1.22, p = 0.188). Stratification by transfer status revealed that among non-transferred patients, complication rates were similar between rural and urban settings (aOR = 0.97, p = 0.067). However, transferred patients in rural areas had significantly higher odds of complications (aOR = 1.21, 95% CI: 1.08–1.37, p = 0.005). Regional analysis showed higher complication rates in the rural Midwest and South but no significant differences in the West and Northeast. Conclusions: Our findings indicate that rural areas experience higher rates of complicated appendicitis, but racial disparities in these settings are absent, likely due to shared geographic barriers that affect all populations equally. In contrast, urban areas exhibit significant racial disparities. The lack of significant differences in complication rates among non-transferred rural patients underscores the critical role of timely access over the quality of care in determining outcomes. Addressing system-level inequities in urban settings and expanding healthcare infrastructure, particularly in vulnerable regions, is essential for achieving equitable patient outcomes.

Authors:
Jeffrey Shupp, Lauren Moffatt, Melissa McLawhorn, Salma Hassan, Shawn Tejiram, Taryn Travis

Body of Abstract:
Introduction
Invasive fungal infections are life-threatening and occur in immunocompromised or critically ill patients. Patients with severe burn injuries are at increased risk for developing invasive fungal infection. Fungal infections are independently associated with increased mortality in burn patients, making early detection in this population paramount. Conventional methods of fungal culture may be unable to detect invasive fungal infection or result in delayed diagnosis. Fungitell® is a diagnostic test that detects (1, 3)-β-D-glucan (BDG) in serum to help diagnose invasive fungal infections. There is a paucity of literature examining the use of BDG assays in burn injured patients to diagnose invasive fungal infection. The aim of this work was to examine the use of BDG assays in a population of severe burn injured patients to determine its utility in guiding antifungal use as well as patient outcomes at a single institution.
Methods
Patients admitted at a single burn center with severe burn injuries estimated to be 15% total body surface area (TBSA) of burn or greater from July 2019 to June 2024 were retrospectively examined. Medical records were reviewed for demographics, injury characteristics, BDG levels, use of antifungals, presence of concomitant bacterial infections, antibiotic therapy, resolution of infection, and mortality. Friedman’s test was used to compare BDG levels across multiple measurements following the initiation of antifungal treatment. A Spearman’s correlation test to analyze the correlation between initial BDG levels and duration of antifungal treatment.
Results
During the study period, 44 patients had BDG levels reported. Of these patients, the most common etiology of burn injury was flame (84.4%). The median (IQR) total body surface area of burn injury was 33.4% (24.8-47.5). Overall mortality rate was 52.3%. Of the patients that had BDG levels measured, 37 were started on antifungal treatment after the initial level was collected (84.1%). Of these patients, only 12 (32.4%) had culture data positive for fungal infection. Discontinuation of treatment was guided by decreasing or negative BDG levels in 73.3% of patients. Among patients with three or more BDG levels obtained, there were increased BDG levels from the first to second measurements [123 (51.75-201.0) vs 159 (113.5-238.8); p=0.007]. However, levels decreased between the second and third measurements [159 (113.5-238.8) vs 126 (85.0-252.0); p=0.004] (Figure 1). There is a weak correlation between initial BDG level and the duration of antifungal treatment (Spearman ρ =0.3194, 95% CI 0.01579-0.5690; p=0.0173).
Conclusion
This data demonstrates that patients were initiated on antifungal treatment after collection of initial BDG level and continued despite negative culture data in many patients, suggesting the utility of BDG assay to guide antifungal use in patients with burn injury. Further study is necessary to elucidate best practices in BDG level use.

Authors:
Christine Cocanour, Michael Campbell, Sarah Lucente

Body of Abstract:
Background: Group A streptococcal (GAS) infection with toxic shock syndrome (TSS) is a rare complication of elective surgery with an incidence of 0.8 to 3.4 per 100,000 and a mortality rate of 1.8-12%; mortality may exceed 50% with misdiagnosis or delay in treatment. High index of suspicion is required when patients do not follow anticipated post-operative trajectory to initiate early treatment and supportive care.

Methods: Case report and review of the current literature.

Results: Rapid onset of hypotension, renal impairment, acute respiratory distress syndrome and a generalized macular rash across the chest and abdomen were observed 24 hours following elective total thyroidectomy. The patient returned to the operating room the evening of post-operative day one where a punctate tracheal injury was observed and wound cultures obtained, the final isolate being streptococcus pyogenes. This was successfully managed with early washout of the operative field, aggressive volume resuscitation, broad spectrum antibiotics with protein synthesis inhibition, and hemodynamic support with four vasopressors including Angiotensin-2 for refractory toxic shock syndrome.

Conclusion: High index of suspicion for TSS as the cause of refractory shock is essential to prevent high rates of mortality. Early re-exploration and source control are essential; the addition of broad-spectrum antibiotics should include protein synthesis inhibition. Angiotensin-2 for refractory shock may be useful in decreasing vasopressor requirements and improve mortality in severe septic shock.