FredricPieracci

The biggest weakness I think is introducing unmeasured bias across patients and centers. #eastjc

In any one direction. If we waited to get to 110 subjects w randomization- study would have taken 10 years- even w 12 centers. I plan on being retired on a beach by then... #eastjc

This of course comes at the expense of potential bias, we we did not find any differences between those who selected surgery and those who didn’t. We showed every subject a standard video explaining that there was no proven benefit to surgery, and had house staff #eastjc

Including an observational arm allowed us to accrue subjects relatively quickly, thereby minimizing other changes in practice over the study timeline, and maintaining enthusiasm. #eastjc

Yes interesting is one word for it! we expected a high rate of refusing randomization- and in fact it was 80%. People (understandably) just weren’t willing to accept a random decision to get an operation. - #eastjc

@RousseauMC And think could be particularly helpful for sub scapular fractures

@FredricPieracci VATS fixation The impact of VATS is minimal, I get significant number of my elective vats lobectomy home on day 1 and the majority by day2-3 so it adds less stress than the current incision I’m making for SSRF in addition to the benefit of htx drainage and nerve blockade #eastjc

I would be very interested in others’ thoughts on what the next RCT in the non-flail population should look like. In NON-FLAIL, we use three or more displaced fractures with respiratory compromise but not intubated. Surgery within 72 hours. #eastjc

@RichLesperance @PMH_Trauma_RPD @JFernandezMDMS @R2_Mitu @traumadmo @bryanacotton1 @elliotthaut @TopKniFe_B @PMHTraumaCripps @MarkHoofnagle @fourmiracles101 @docmartin22 @LindaDultz Fractures

@PMH_Trauma_RPD @JFernandezMDMS @R2_Mitu @traumadmo @bryanacotton1 @elliotthaut @TopKniFe_B @PMHTraumaCripps @MarkHoofnagle @fourmiracles101 @docmartin22 @LindaDultz Our pain team here is VERY aggressive with epidurals, but we have to hold one dose of lovenox for placement. This makes me very interested in the ES block, since we know holding even 1 lovenox dose raises DVT risk.... #eastjc

Welcome to May’s #eastjc! Very excited to introduce @FredricPieracci @AdamShiroff @AndrewDoben @SebastianSchubl and welcome all members of @EAST_TRAUMA and @CWISociety for this month’s #eastjc focusing on chest wall injury. Today we will be engaging the experts on hot topics 1/2

@RichLesperance @PMH_Trauma_RPD @JFernandezMDMS @R2_Mitu @traumadmo @bryanacotton1 @elliotthaut @TopKniFe_B @PMHTraumaCripps @MarkHoofnagle @fourmiracles101 @docmartin22 @LindaDultz I agree with the DVT prophylaxis issue; the most common problems at our hospital are stringent definition of a coagulopathy (INR > 1.5), sympathectomy that causes hypotension, particularly in elderly patients, resulting in unnecessary volume expansion, and relatively minor spine

@RousseauMC I agree

@JFernandezMDMS @EAST_TRAUMA @CWISociety Agree - very long term benefit to SSRF is currently unknown.

@FredricPieracci #eastjc are you planning on a long term >60 mo patient center outcomes study? for those who return to work doing physical activity SSRF may provide a benefit. Thoughts @EAST_TRAUMA @CWISociety

We thought it was important to have an outpatient outcome as primary, because we knew we were studying a less severely injured group and inpatient outcomes like mortality and ventilator days would be much more rare versus the flower trials. But, we knew follow up would . #eastjc

@JFernandezMDMS @traumadmo @RousseauMC @LindaDultz @PMH_Trauma_RPD @R2_Mitu @bryanacotton1 @elliotthaut @TopKniFe_B @PMHTraumaCripps @MarkHoofnagle @fourmiracles101 @docmartin22 @EAST_TRAUMA Definitely. I am happy to share our protocols and data collection tools, etc. for our single center RCT of pain cath vs. liposomal here in Denver.

@traumadmo @RousseauMC @LindaDultz @PMH_Trauma_RPD @R2_Mitu @bryanacotton1 @elliotthaut @TopKniFe_B @PMHTraumaCripps @MarkHoofnagle @fourmiracles101 @docmartin22 Sounds like a nice @EAST_TRAUMA multi-center trial #eastjc

@JFernandezMDMS @EASTjournalclub @EAST_TRAUMA @CWISociety Yes, CWIS is planning multicenter RCT- frank Zhao (trauma surgeon in San Diego) is PI.

@FredricPieracci We mentioned it briefly yesterday but is anyone looking into the use of cryoablation nerve blocks? #eastjc @EASTjournalclub @EAST_TRAUMA @CWISociety

We are actually doing a single center RCT in Denver of Pain catheter versus one time liposomal bupivacaine injection in the OR during SSRF. 31/45 subjects enrolled. I think there will be some power issues. This kind of question would be great for a multi center study.#eastjc

Flail (not flower)

Be an issue. So we compromised on two weeks. Pain scores and quality-of-life were improved in the operative arm. Unfortunately narcotics did not reach significance(the dreaded p=0.05), But we still saw a strong signal out to eight week follow up. #eastjc

Thanks very much for discussing our article. Looking forward to it. #eastjc