1
|
Kirkendoll SD, Hink AB, Kuhls DA, Rivara FP, Sakran JV, Agoubi LL, Winchester AS, Richards J, Hoeft C, Patel B, Michaels H, Nathens AB. Characteristics of Firearm Injury by Injury Intent: The Need for Tailored Interventions. J Trauma Acute Care Surg 2024:01586154-990000000-00704. [PMID: 38654417 DOI: 10.1097/ta.0000000000004344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
INTRODUCTION While the U.S. has high quality data on firearm-related deaths, less information is available on those who arrive at trauma centers alive, especially those discharged from the emergency department. This study sought to describe characteristics of patients arriving to trauma centers alive following a firearm injury, postulating that significant differences in firearm injury intent might provide insights into injury prevention strategies. METHODS This was a multi-center prospective cohort study of patients treated for firearm-related injuries at 128 U.S. trauma centers from 3/2021-2/2022. Data collected included patient-level sociodemographic, injury and clinical characteristics, community characteristics, and context of injury. The outcome of interest was the association between these factors and the intent of firearm injury. Measures of urbanicity, community distress, and strength of state firearm laws were utilized to characterize patient communities. RESULTS 15,232 patients presented with firearm-related injuries across 128 centers in 41 states. Overall, 9.5% of patients died, and deaths were more common among law enforcement and self-inflicted (SI) firearm injuries (80.9% and 50.5%, respectively). These patients were also more likely to have a history of mental illness. SI firearm injuries were more common in older White men from rural and less distressed communities, whereas firearm assaults were more common in younger, Black men from urban and more distressed communities. Unintentional injuries were more common among younger patients and in states with lower firearm safety grades whereas law enforcement-related injuries occurred most often in unemployed patients with a history of mental illness. CONCLUSIONS Injury, clinical, sociodemographic, and community characteristics among patients injured by a firearm significantly differed between intents. With the goal of reducing firearm-related deaths, strategies and interventions need to be tailored to include community improvement and services that address specific patient risk factors for firearm injury intent. LEVEL OF EVIDENCE Level III, Prognostic/Epidemiological.
Collapse
Affiliation(s)
| | - Ashley B Hink
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Deborah A Kuhls
- Department of Surgery. Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, NV
| | - Frederick P Rivara
- Departments of Pediatrics and Epidemiology and the Firearm Injury and Policy Research Program, University of Washington, Seattle, WA
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins Medicine, Baltimore, MD
| | - Lauren L Agoubi
- Harborview Injury Prevention and Research Center and the Department of Surgery, University of Washington, Seattle, WA
| | | | | | | | | | | | | |
Collapse
|
2
|
Zufer I, Fix RL, Stone E, Cane R, Sakran JV, Nasr I, Hoops K. Documentation of Trauma-Informed Care Elements for Young People Hospitalized After Assault Trauma. J Surg Res 2024; 296:665-673. [PMID: 38359681 DOI: 10.1016/j.jss.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 01/01/2024] [Accepted: 01/16/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION Violent traumatic injury, including firearm violence, can adversely impact individual and community health. Trauma-informed care (TIC) can promote resilience and prevent future violence in patients who have experienced trauma. However, few protocols exist to facilitate implementation of TIC for patients who survive traumatic injury. The purpose of the study is to characterize documentation of TIC practices and identify opportunities for intervention in a single academic quaternary care center. METHODS This study is a retrospective chart review analyzing the documentation of trauma-informed elements in the electronic medical record of a random sample of youth patients (ages 12-23) admitted for assault trauma to the pediatric (n = 50) and adult trauma (n = 200) services between 2016 and mid-2021. Descriptive statistics were used to summarize patient demographics, hospitalization characteristics, and documentation of trauma-informed elements. Chi-square analyses were performed to compare pediatric and adult trauma services. RESULTS Among pediatric and adult assault trauma patients, 36.0% and 80.5% were hospitalized for firearm injury, respectively. More patients admitted to the pediatric trauma service (96%) had at least one trauma-informed element documented than patients admitted to the adult service (82.5%). Social workers were the most likely clinicians to document a trauma-informed element. Pain assessment and social support were most frequently documented. Safety assessments for suicidal ideation, retaliatory violence, and access to a firearm were rarely documented. CONCLUSIONS Results highlight opportunities to develop trauma-informed interventions for youth admitted for assault trauma. Standardized TIC documentation could be used to assess risk of violent reinjury and mitigate sequelae of trauma.
Collapse
Affiliation(s)
- Insia Zufer
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca L Fix
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth Stone
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rachel Cane
- Division of Pediatric Hospital Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - Joseph V Sakran
- Johns Hopkins Medicine, Department of Surgery, Baltimore, Maryland
| | - Isam Nasr
- Johns Hopkins Medicine, Department of Surgery, Baltimore, Maryland
| | - Katherine Hoops
- Department of Anesthesiology and Critical Care Medicine, Department of Health Policy and Management, Johns Hopkins Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| |
Collapse
|
3
|
Scrushy M, Lunardi N, Sakran JV. Trauma Demographics and Injury Prevention. Surg Clin North Am 2024; 104:243-254. [PMID: 38453299 DOI: 10.1016/j.suc.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Traumatic injury is a leading cause of death in the United States. Risk of traumatic injury varies by sex, age, geography, and race/ethnicity. Understanding the nuances of risk for a particular population is essential in designing, implementing, and evaluating injury prevention initiatives.
Collapse
Affiliation(s)
- Marinda Scrushy
- Department of General Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Nicole Lunardi
- Department of General Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins Hospital, 1800 Orleans Street, Sheikh Zayed Tower / Suite 6107A, Baltimore, MD 21287, USA.
| |
Collapse
|
4
|
Sakran JV, Lunardi N, Mehta A, Ezzeddine HM, Chammas M, Fransman R, Byrne JP, Stevens K, Efron D. Increasing Injury Intensity among 6,500 Violent Deaths in the State of Maryland. J Am Coll Surg 2024; 238:710-717. [PMID: 38230851 DOI: 10.1097/xcs.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Anecdotal evidence strongly suggests there has been a rise in violent crimes. This study sought to examine trends in injury characteristics of homicide victims in Maryland. We hypothesized that there would be an increase in the severity of wound characteristics. STUDY DESIGN The Office of the Chief Medical Examiner is a statewide agency designated by law to investigate all homicides, suicides, or unusual or suspicious circumstances. Using individual autopsy reports, we collected data among all homicides from 2005 to 2017, categorizing them into 3 time periods: 2005 to 2008 (early), 2009 to 2013 (mid), and 2014 to 2017 (late). Primary outcomes included the number of gunshots, stabs, and fractures from assaults. High-violence intensity outcomes included victims having 10 or more gunshots, 5 or more stabs, or 5 or more fractures from assaults. RESULTS Of 6,500 homicides (annual range 403 to 589), the majority were from firearms (75%), followed by stabbings (14%) and blunt assaults (10%). Most homicide victims died in the hospital (60%). The average number of gunshots per victim was 3.9 (range 1 to 54), stabs per victim was 9.4 (range 1 to 563), and fractures from assaults per victim was 3.7 (range 0 to 31). The proportion of firearm victims with at least 10 gunshots nearly doubled from 5.7% in the early period to 10% (p < 0.01) in the late period. Similarly, the proportion with 5 or more stabbings increased from 39% to 50% (p = 0.02) and assault homicides with 5 or more fractures increased from 24% to 38% (p < 0.01). CONCLUSIONS In Maryland, the intensity of violence increased across all major mechanisms of homicide. Further follow-up studies are needed to elucidate the root causes underlying this escalating trend.
Collapse
Affiliation(s)
- Joseph V Sakran
- From the Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD (Sakran, Byrne, Stevens)
| | - Nicole Lunardi
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX (Lunardi)
| | - Ambar Mehta
- Department of Surgery, Massachusetts General Hospital, Boston, MA (Mehta)
| | - Hiba M Ezzeddine
- Department of Surgery, Mary Washington Healthcare, Fredericksburg, VA (Ezzeddine)
| | - Majid Chammas
- Department of Surgery, University of Miami/JFK Medical Center, Miami, FL (Chammas)
| | - Ryan Fransman
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD (Fransman, Efron)
| | - James P Byrne
- From the Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD (Sakran, Byrne, Stevens)
| | - Kent Stevens
- From the Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD (Sakran, Byrne, Stevens)
| | - David Efron
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD (Fransman, Efron)
| |
Collapse
|
5
|
Torres CM, Kenzik KM, Saillant NN, Scantling DR, Sanchez SE, Brahmbhatt TS, Dechert TA, Sakran JV. Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients. JAMA Surg 2024; 159:374-381. [PMID: 38294820 PMCID: PMC10831629 DOI: 10.1001/jamasurg.2023.7178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/01/2023] [Indexed: 02/01/2024]
Abstract
Importance Civilian trauma centers have revived interest in whole-blood (WB) resuscitation for patients with life-threatening bleeding. However, there remains insufficient evidence that the timing of WB transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome. Objective To evaluate whether earlier timing of first WB transfusion is associated with improved survival at 24 hours and 30 days for adult trauma patients presenting with severe hemorrhage. Design, Setting, and Participants This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019, to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. Patients with burns, prehospital cardiac arrest, deaths within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from January 3 to October 2, 2023. Exposure Patients who received WB as an adjunct to MTP (earlier) compared with patients who had yet to receive WB as part of MTP (later) at any given time point within 24 hours of ED arrival. Main Outcomes and Measures Primary outcomes were survival at 24 hours and 30 days. Results A total of 1394 patients met the inclusion criteria (1155 male [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included profoundly injured patients (median Injury Severity Score, 27 [IQR, 17-35]). A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion. Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with improved survival at 24 hours (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003). Similarly, the survival benefit of earlier WB transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < .001). Conclusions and Relevance In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival was associated with improved survival in patients presenting with severe hemorrhage. The survival benefit was noted shortly after transfusion. The findings of this study are clinically important as the earlier timing of WB administration may offer a survival advantage in actively hemorrhaging patients requiring MTP.
Collapse
Affiliation(s)
- Crisanto M. Torres
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kelly M. Kenzik
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Noelle N. Saillant
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Dane R. Scantling
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Sabrina E. Sanchez
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Tejal S. Brahmbhatt
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Tracey A. Dechert
- Division of Trauma and Acute Care Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Joseph V. Sakran
- Johns Hopkins School of Medicine, Baltimore, Maryland
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
- Johns Hopkins School of Nursing, Baltimore, Maryland
- Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia
| |
Collapse
|
6
|
Miller AN, Strelzow JA, Sakran JV, Ficke JR. AOA Critical Issues Symposium: Gun Violence as a Public Health Crisis. J Bone Joint Surg Am 2024:00004623-990000000-01043. [PMID: 38502726 DOI: 10.2106/jbjs.23.01260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
ABSTRACT Gun violence is an epidemic throughout the United States and is increasing around the world-it is a public health crisis. The impact of gun violence is not limited to the victims (our patients); it also extends to the physicians and caregivers who are taking care of these patients every day. Even more broadly, gun violence affects those living and going to work in potentially dangerous environments. The "vicarious trauma" that is experienced in these situations can have long-term effects on physicians, nurses, and communities. Importantly, socioeconomic disparities and community deprivation strongly correlate with gun violence. Systemic factors that are deeply ingrained in our society can increase concerns for these underrepresented patient populations and cause increased stressors with substantial health consequences, including delayed fracture-healing and poorer overall health outcomes. It is incumbent on us as physicians to take an active role in speaking up for our patients. The importance of advocacy efforts to change policy (not politics) and continue to push for improvement in the increasingly challenging environments in which patients and physicians find themselves cannot be overstated. Multiple national organizations, including many orthopaedic and general surgery associations, have made statements advocating for change. The American College of Surgeons, in collaboration with many other medical organizations, has supported background checks, registration, licensure, firearm education and training, safe storage practices, red flag laws, addressing mental health issues, and more research to better inform an approach going forward and to address the root causes of violence. We encourage the orthopaedic surgery community to stand together to protect each other and our patients, both physically and mentally, with agreement on these principles.
Collapse
Affiliation(s)
- Anna N Miller
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Jason A Strelzow
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, Illinois
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - James R Ficke
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| |
Collapse
|
7
|
Lunardi N, Abou-Zamzam A, Florecki KL, Chidambaram S, Shih IF, Kent AJ, Joseph B, Byrne JP, Sakran JV. Robotic Technology in Emergency General Surgery Cases in the Era of Minimally Invasive Surgery. JAMA Surg 2024:2815665. [PMID: 38446451 PMCID: PMC10918578 DOI: 10.1001/jamasurg.2024.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/03/2023] [Indexed: 03/07/2024]
Abstract
Importance Although robotic surgery has become an established approach for a wide range of elective operations, data on its utility and outcomes are limited in the setting of emergency general surgery. Objectives To describe temporal trends in the use of laparoscopic and robotic approaches and compare outcomes between robotic and laparoscopic surgery for 4 common emergent surgical procedures. Design, Setting, and Participants A retrospective cohort study of an all-payer discharge database of 829 US facilities was conducted from calendar years 2013 to 2021. Data analysis was performed from July 2022 to November 2023. A total of 1 067 263 emergent or urgent cholecystectomies (n = 793 800), colectomies (n = 89 098), inguinal hernia repairs (n = 65 039), and ventral hernia repairs (n = 119 326) in patients aged 18 years or older were included. Exposure Surgical approach (robotic, laparoscopic, or open) to emergent or urgent cholecystectomy, colectomy, inguinal hernia repair, or ventral hernia repair. Main Outcomes and Measures The primary outcome was the temporal trend in use of each operative approach (laparoscopic, robotic, or open). Secondary outcomes included conversion to open surgery and length of stay (both total and postoperative). Temporal trends were measured using linear regression. Propensity score matching was used to compare secondary outcomes between robotic and laparoscopic surgery groups. Results During the study period, the use of robotic surgery increased significantly year-over-year for all procedures: 0.7% for cholecystectomy, 0.9% for colectomy, 1.9% for inguinal hernia repair, and 1.1% for ventral hernia repair. There was a corresponding decrease in the open surgical approach for all cases. Compared with laparoscopy, robotic surgery was associated with a significantly lower risk of conversion to open surgery: cholecystectomy, 1.7% vs 3.0% (odds ratio [OR], 0.55 [95% CI, 0.49-0.62]); colectomy, 11.2% vs 25.5% (OR, 0.37 [95% CI, 0.32-0.42]); inguinal hernia repair, 2.4% vs 10.7% (OR, 0.21 [95% CI, 0.16-0.26]); and ventral hernia repair, 3.5% vs 10.9% (OR, 0.30 [95% CI, 0.25-0.36]). Robotic surgery was associated with shorter postoperative lengths of stay for colectomy (-0.48 [95% CI, -0.60 to -0.35] days), inguinal hernia repair (-0.20 [95% CI, -0.30 to -0.10] days), and ventral hernia repair (-0.16 [95% CI, -0.26 to -0.06] days). Conclusions and Relevance While robotic surgery is still not broadly used for emergency general surgery, the findings of this study suggest it is becoming more prevalent and may be associated with better outcomes as measured by reduced conversion to open surgery and decreased length of stay.
Collapse
Affiliation(s)
- Nicole Lunardi
- Department of Surgery, University of Texas Southwestern, Dallas
| | - Aida Abou-Zamzam
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - I-Fan Shih
- Global Access Value Economics, Intuitive Surgical, Sunnyvale, California
| | - Alistair J. Kent
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson
| | - James P. Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph V. Sakran
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
8
|
Butts CA, Byerly S, Nahmias J, Gelbard R, Ziesmann M, Bruns B, Davidson GH, Di Saverio S, Esposito TJ, Fischkoff K, Joseph B, Kaafarani H, Mentula P, Podda M, Sakran JV, Salminen P, Sammalkorpi H, Sawyer RG, Skeete D, Tesoriero R, Yeh DD. A core outcome set for appendicitis: A consensus approach utilizing modified Delphi methodology. J Trauma Acute Care Surg 2024; 96:487-492. [PMID: 37751156 DOI: 10.1097/ta.0000000000004144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pathologies encountered by general and acute care surgeons. The current literature is inconsistent, as it is fraught with outcome heterogeneity, especially in the area of nonoperative management. We sought to develop a core outcome set (COS) for future appendicitis studies to facilitate outcome standardization and future data pooling. METHODS A modified Delphi study was conducted after identification of content experts in the field of appendicitis using both the Eastern Association for the Surgery of Trauma (EAST) landmark appendicitis articles and consensus from the EAST ad hoc COS taskforce on appendicitis. The study incorporated three rounds. Round 1 utilized free text outcome suggestions, then in rounds 2 and 3 the suggests were scored using a Likert scale of 1 to 9 with 1 to 3 denoting a less important outcome, 4 to 6 denoting an important but noncritical outcome, and 7 to 9 denoting a critically important outcome. Core outcome status consensus was defined a priori as >70% of scores 7 to 9 and <15% of scores 1 to 3. RESULTS Seventeen panelists initially agreed to participate in the study with 16 completing the process (94%). Thirty-two unique potential outcomes were initially suggested in round 1 and 10 (31%) met consensus with one outcome meeting exclusion at the end of round 2. At completion of round 3, a total of 17 (53%) outcomes achieved COS consensus. CONCLUSION An international panel of 16 appendicitis experts achieved consensus on 17 core outcomes that should be incorporated into future appendicitis studies as a minimum set of standardized outcomes to help frame future cohort-based studies on appendicitis. LEVEL OF EVIDENCE Diagnostic Test or Criteria; Level V.
Collapse
Affiliation(s)
- Christopher A Butts
- From the Division of Trauma, Acute Care Surgery & Surgical Critical Care (C.A.B.), Department of Surgery, Reading Hospital-Tower Health, West Reading, Pennsylvania; Department of Surgery, University of Tennessee Health Science Center (S.B.), Memphis, Tennessee; UC Irvine Healthcare, Orange (J.N.), California; Department of Surgery, University of Alabama at Birmingham (R.G.), Birmingham, Alabama; University of Manitoba, Winnipeg (M.Z.), Manitoba, Canada; Department of Surgery, University of Texas Southwestern, Dallas (B.B.), Texas; Department of Surgery, University of Washington, Seattle (G.H.D.), Washington; AST5 ASR Marche, Hospital Madonna del Soccorso (S.D.S.), San Benedetto del Tronto, Italy; Department of Medicine, University of Illinois School of Medicine (T.J.E.), Peoria, Illinois; Department of Surgery, Columbia University Irving Medical Center (K.F.), New York, New York; Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery (B.J.), College of Medicine, University of Arizona, Tuscon, Arizona; Trauma, Emergency Surgery, and Surgical Critical Care (H.K.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Gastroenterological Surgery (P.M., H.S.), Helsinki University Hospital, Helsinki, Finland; Department of General and Emergency Surgery (M.P.), Cagliari University Hospital, Cagliari, Italy; Division of Acute Care Surgery, Department of Surgery (J.V.S.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Surgery (P.S.), University of Turku, Turku, Finland; Department of Surgery, Western Michigan University School of Medicine: Western Michigan University Homer Stryker MD School of Medicine (R.G.S.), Kalamazoo, Michigan; Roy J. and Lucille A. Carver College of Medicine (D.S.), University of Iowa, Iowa City, Iowa; Division of General Surgery, Trauma and Surgical Critical Care, Acute Care Surgery (R.T.), Zuckerberg San Francisco General Hospital, San Francisco, California; and Ernest E Moore Shock Trauma Center at Denver Health (D.D.Y.), University of Colorado, Denver, Colorado
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Patel VR, Rozycki G, Jopling J, Subramanian M, Kent A, Manukyan M, Sakran JV, Haut E, Levy M, Nathens AB, Brown C, Byrne JP. Association Between Geospatial Access to Trauma Center Care and Motor Vehicle Crash Mortality in the United States. J Trauma Acute Care Surg 2023:01586154-990000000-00580. [PMID: 38053239 DOI: 10.1097/ta.0000000000004221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Motor vehicle crashes (MVCs) are a leading cause of preventable trauma death in the United States (US). Access to trauma center care is highly variable nationwide. The objective of this study was to measure the association between geospatial access to trauma center care and MVC mortality. METHODS This was a population-based study of MVC-related deaths that occurred in 3,141 US counties (2017-2020). ACS and state-verified level I-III trauma centers were mapped. Geospatial network analysis estimated the ground transport time to the nearest trauma center from the population-weighted centroid for each county. In this way, the exposure was the predicted access time to trauma center care for each county population. Hierarchical negative binomial regression measured the risk-adjusted association between predicted access time and MVC mortality, adjusting for population demographics, rurality, access to trauma resources, and state traffic safety laws. RESULTS We identified 92,398 crash fatalities over the four-year study period. Trauma centers mapped included 217 level I, 343 level II, and 495 level III trauma centers. The median county predicted access time was 47 min (IQR 26-71 min). Median county MVC mortality was 12.5 deaths/100,000 person-years (IQR 7.4-20.3 deaths/100,000 person-years). After risk-adjustment, longer predicted access times were significantly associated with higher rates of MVC mortality (>60 min vs. <15 min; MRR 1.36; 95%CI 1.31-1.40). This relationship was significantly more pronounced in urban/suburban vs. rural/wilderness counties (p for interaction, <0.001). County access to trauma center care explained 16% of observed state-level variation in MVC mortality. CONCLUSIONS Geospatial access to trauma center care is significantly associated with MVC mortality and contributes meaningfully to between-state differences in road traffic deaths. Efforts to improve trauma system organization should prioritize access to trauma center care to minimize crash fatalities. LEVEL OF EVIDENCE Level III, Epidemiological.
Collapse
Affiliation(s)
- Vishal R Patel
- Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Grace Rozycki
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeffrey Jopling
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Madhu Subramanian
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alistair Kent
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mariuxi Manukyan
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | | | | |
Collapse
|
10
|
Rozycki GF, Sakran JV, Manukyan MC, Feliciano DV, Radisic A, You B, Hu F, Wooster M, Noll K, Haut ER. Angioembolization May Improve Survival in Patients With Severe Hepatic Injuries. Am Surg 2023; 89:5492-5500. [PMID: 36786019 DOI: 10.1177/00031348231157416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
INTRODUCTION Although reports on angioembolization (AE) show favorable results for severe hepatic trauma, information is lacking on its benefit in the management and mechanisms of injury (MOI). This study examined patient outcomes with severe hepatic injuries to determine the association of in-hospital mortality with AE. The hypothesis is that AE is associated with increased survival in severe hepatic injuries. METHODS Demographics, age, sex, MOI, shock index (SI), ≥6 units packed red blood cells (PRBCs) per hospital length of stay (LOS), intensive care unit LOS, injury severity score (ISS), and AE were collected. The primary outcome was in-hospital mortality. Patients were stratified into groups according to MOI, AE, and operative vs non-operative management. Multivariable logistic regression determined the independent association of mortality with AE vs no AE and operative vs nonoperative management and modeled the odds of mortality controlling for MOI, AE vs no AE, age and ISS groups, SI >.9, and ≥6 units PRBCs/LOS. RESULTS From 2013 to 2018, 2462 patients (1744 blunt; 718 penetrating) were treated for severe hepatic injuries. AE was used in only 21% of patients. Mortality rates increased with higher ISS and age. AE was associated with mortality when compared to patients who did not undergo AE. The strongest associations with mortality were ISS ≥25, transfusion ≥ 6 units PRBCs/LOS, and age ≥65 years. CONCLUSIONS AE is underutilized in severe hepatic trauma. AE may be a valuable adjunct in the treatment of severe hepatic injuries especially in older patients and those needing exploratory laparotomy.
Collapse
Affiliation(s)
- Grace F Rozycki
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph V Sakran
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mariuxi C Manukyan
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David V Feliciano
- Shock Trauma Center/University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amanda Radisic
- Department of Surgery, School of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Bin You
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fang Hu
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meghan Wooster
- Southeast Iowa Regional Medical Center, Burlington, IA, USA
| | - Kathy Noll
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
11
|
Torres CM, Haut ER, Sakran JV. Potential Limitations for Assessing the Association of Whole Blood With Survival in Patients With Severe Hemorrhage-Reply. JAMA Surg 2023; 158:1227-1228. [PMID: 37378993 DOI: 10.1001/jamasurg.2023.1843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Affiliation(s)
- Crisanto M Torres
- Division of Trauma and Acute Care Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Elliott R Haut
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph V Sakran
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
12
|
Torres CM, Florecki K, Haghshenas J, Manukyan M, Kent A, Lawrence C, Sakran JV. The evolution and development of a robotic acute care surgery program. J Trauma Acute Care Surg 2023; 95:e26-e30. [PMID: 37277903 DOI: 10.1097/ta.0000000000004020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Acute care surgeons perform more than 850,000 operations annually on emergency general surgery patients in the United States. Emergency general surgery conditions are associated with a disproportionate excess of patient complications and death. Innovative quality improvement strategies have focused on addressing the excess morbidity and mortality among this patient population. Minimally invasive surgical techniques have been shown to reduce the burden experienced by emergency general surgery patients. Still, limited adoption by acute care surgeons has restricted this application's potential. An institutional robotics acute care surgery program provides acute care surgeons additional opportunities to expand minimally invasive surgery access to emergency general surgery patients irrespective of the time or day of the week. METHODS A robotics acute care surgery program was developed and implemented at a high-volume academic institution within the division of trauma and acute care surgery. RESULTS Three attending surgeons and two fellows within the trauma and acute care surgery division had successfully completed a defined robotics clinical pathway. As a result, around-the-clock use of a robotic surgical platform for emergency general surgery cases was implemented with routine use by trained robotic acute care surgeons and practicing fellows. CONCLUSION The advancement of robotic surgical technology has opened new avenues for surgical application in the emergency setting. The development of a robotic acute care surgery program allows acute care surgeons to diversify their practice while providing greater access to minimally invasive approaches for emergency general surgery patients.
Collapse
Affiliation(s)
- Crisanto M Torres
- From the Division of Trauma and Acute Care Surgery (C.M.T.), Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts; Division of Acute Care Surgery (K.F., M.M., A.K., J.V.S.), Johns Hopkins Hospital, Baltimore, Maryland; Division of Trauma and Acute Care Surgery (J.H.), University of Illinois-Chicago School of Medicine, Chicago, Illinois; Department of Surgery (J.V.S.), Johns Hopkins School of Medicine, Baltimore, Maryland; and Department of Surgery (C.L.), Johns Hopkins School of Nursing, Baltimore, Maryland
| | | | | | | | | | | | | |
Collapse
|
13
|
Haghshenas J, Florecki K, Torres CM, Manukyan M, Kent A, Lawrence C, Sakran JV. Incorporation of a robotic surgery training curriculum in acute care surgical fellowship. J Trauma Acute Care Surg 2023; 95:e11-e14. [PMID: 37125919 DOI: 10.1097/ta.0000000000003996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- Jafar Haghshenas
- From the Division of Trauma and Acute Care Surgery (J.H.), Advocate Christ Medical Center, University of Illinois-Chicago School of Medicine, Chicago, Illinois; Division of Acute Care Surgery (K.F., M.M., A.K., J.V.S.), Johns Hopkins Hospital, Baltimore, Maryland; Division of Trauma and Acute Care Surgery (C.M.T.), Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts; Johns Hopkins School of Medicine (J.V.S.), Baltimore, Maryland; and Johns Hopkins School of Nursing (C.L., J.V.S.), Baltimore, Maryland
| | | | | | | | | | | | | |
Collapse
|
14
|
Rapaport S, Ngude H, Ficke JR, Yenokyan G, Rafiq MY, Juma O, Sakran JV, Stevens KA, Enumah ZO. What Proportion of East African Refugees Report Musculoskeletal Problems? A Cross-sectional Survey. Clin Orthop Relat Res 2023; 482:00003086-990000000-01231. [PMID: 37470791 PMCID: PMC10723852 DOI: 10.1097/corr.0000000000002729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/14/2023] [Accepted: 05/10/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Musculoskeletal conditions are the leading cause of disability worldwide and disproportionally affect individuals in low-income and middle-income countries. There is a dearth of evidence on musculoskeletal problems among refugees, 74% of whom reside in low-income and middle-income countries. QUESTIONS/PURPOSES (1) What proportion of refugees in Nyarugusu Camp, Kigoma, western Tanzania, are affected by musculoskeletal problems and what are the characteristics of those individuals? (2) What are the characteristics of these musculoskeletal problems, including their causes, location, and duration? (3) What forms of healthcare do those with musculoskeletal problems seek, including those for both musculoskeletal and nonmusculoskeletal problems? METHODS We conducted a cross-sectional study among refugees in Nyarugusu Camp, using the Surgeons OverSeas Assessment of Surgical Need tool. The Surgeons OverSeas Assessment of Surgical Need tool is a validated population-based survey tool developed for use in limited-resource settings that is intended to determine the prevalence of surgical disease in a community. It uses a cluster random sampling methodology with house-to-house data collection in the form of a verbal head-to-toe examination that is performed by a trained community healthcare worker. A total of 99% responded, and 3574 records were analyzed. The mean age of respondents was 23 ± 18 years, with under 18 as the most-represented age group (44% [1563]). A total of 57% (2026) of respondents were women, 79% (2802 of 3536) were generally healthy, and 92% (3297 of 3570) had visited a camp medical facility. Only records endorsing musculoskeletal problems (extremity or back) were included in this analysis. Using all refugees surveyed as our denominator and refugees who endorsed a musculoskeletal problem (extremity or back) as the numerator, we calculated the proportion of refugees who endorsed a musculoskeletal problem. We then analyzed the characteristics of those endorsing musculoskeletal problems, including their healthcare-seeking behavior, and the characteristics of the musculoskeletal problems themselves. RESULTS Among 3574 refugees interviewed, 22% (769) reported musculoskeletal problems, with 17% (609) reporting extremity problems and 7% (266) reporting back problems. Among all people surveyed, 8% (290) reported current extremity problems while 5% (188) reported current back problems. Among those reporting musculoskeletal problems, respondents younger than 18 years were the most-represented age group (28% [169 of 609]) whereas respondents between 30 and 44 years of age were the most-represented age group for back problems (29% [76 of 266]). Wounds from an injury or trauma (24% [133 of 557]) and acquired disability (24% [133 of 557]) were the most-common causes of extremity problems, whereas acquired disability (53% [97 of 184]) followed by a wound not from injury or trauma (25% [45 of 184]) were the most common causes of back problems. Fifty percent (303) of those with extremity problems characterized it as disabling, whereas 76% (203) of those with back problems did. CONCLUSION Over one of five refugees endorsed musculoskeletal problems, which are most often caused by acquired disease and injury. These musculoskeletal problems are often characterized as disabling, yet only slightly more than half have sought treatment for problems. This warrants further research on care-seeking behavior in this setting, and emphasizes that investing in the spectrum of musculoskeletal health systems, including medical management and rehabilitation services, is critical to decreasing disability caused by musculoskeletal problems. LEVEL OF EVIDENCE Level IV, prognostic study.
Collapse
Affiliation(s)
- Sarah Rapaport
- Global Surgery Initiative, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Hilary Ngude
- Tanzania Red Cross Society, Dar es Salaam, Tanzania
| | - James R. Ficke
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | | | - Omar Juma
- Ifakara Health Institute, Ifakara, Tanzania
| | - Joseph V. Sakran
- Global Surgery Initiative, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kent A. Stevens
- Global Surgery Initiative, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Zachary Obinna Enumah
- Global Surgery Initiative, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
| |
Collapse
|
15
|
Dunton Z, Seamon MJ, Subramanian M, Jopling J, Manukyan M, Kent A, Sakran JV, Stevens K, Haut E, Byrne JP. Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery. J Trauma Acute Care Surg 2023; 95:69-77. [PMID: 36850033 DOI: 10.1097/ta.0000000000003907] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Hemorrhage control surgery is an essential trauma center function. Airway management of the unstable bleeding patient in the emergency department (ED) presents a challenge. Premature intubation in the ED can exacerbate shock and precipitate extremis. We hypothesized that ED versus operating room intubation of patients requiring urgent hemorrhage control surgery is associated with adverse outcomes at the patient and hospital-levels. METHODS Patients who underwent hemorrhage control within 60 minutes of arrival at level 1 or 2 trauma centers were identified (National Trauma Data Bank 2017-2019). To minimize confounding, patients dead on arrival, undergoing ED thoracotomy, or with clinical indications for intubation (severe head/neck/face injury or Glasgow Coma Scale score of ≤8) were excluded. Two analytic approaches were used. First, hierarchical logistic regression measured the risk-adjusted association between ED intubation and mortality. Secondary outcomes included ED dwell time, units of blood transfused, and major complications (cardiac arrest, acute respiratory distress syndrome, acute kidney injury, sepsis). Second, a hospital-level analysis determined whether hospital tendency ED intubation was associated with adverse outcomes. RESULTS We identified 9,667 patients who underwent hemorrhage control surgery at 253 trauma centers. Patients were predominantly young men (median age, 33 years) who suffered penetrating injuries (71%). The median initial Glasgow Coma Scale and systolic blood pressure were 15 and 108 mm Hg, respectively. One in five (20%) of patients underwent ED intubation. After risk-adjustment, ED intubation was associated with significantly increased odds of mortality, longer ED dwell time, greater blood transfusion, and major complications. Hospital-level analysis identified significant variation in use of ED intubation between hospitals not explained by patient case mix. After risk adjustment, patients treated at hospitals with high tendency for ED intubation (compared with those with low tendency) were significantly more likely to suffer in-hospital cardiac arrest (6% vs. 4%; adjusted odds ratio, 1.46; 95% confidence interval, 1.04-2.03). CONCLUSION Emergency department intubation of patients who require urgent hemorrhage control surgery is associated with adverse outcomes. Significant variation in ED intubation exists between trauma centers not explained by patient characteristics. Where feasible, intubation should be deferred in favor of rapid resuscitation and transport to the operating room. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
Affiliation(s)
- Zachary Dunton
- From the School of Medicine and Public Health (Z.D.), University of Wisconsin-Madison, Madison, Wisconsin; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery (M.J.S.), University of Pennsylvania, Philadelphia, Pennsylvania; and Division of Trauma and Acute Care Surgery, Department of Surgery (M.S., J.J., M.M., A.K., J.V.S., K.S., E.H., J.P.B.), Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Rapaport S, Enumah ZO, Ngude H, Rhee DS, Abbas M, Lekey A, Winch PJ, Sakran JV, Stevens KA. Patterns, procedures, and indications for pediatric surgery in a Tanzanian Refugee Camp: a 20-year experience. World J Pediatr Surg 2023; 6:e000528. [PMID: 37396496 PMCID: PMC10314687 DOI: 10.1136/wjps-2022-000528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/24/2023] [Indexed: 07/04/2023] Open
Abstract
Background There are 103 million displaced people worldwide, 41% of whom are children. Data on the provision of surgery in humanitarian settings are limited. Even scarcer is literature on pediatric surgery performed in humanitarian settings, particularly protracted humanitarian settings. Methods We reviewed patterns, procedures, and indications for pediatric surgery among children in Nyarugusu Refugee Camp using a 20-year retrospective dataset. Results A total of 1221 pediatric surgical procedures were performed over the study period. Teenagers between the ages of 12 and 17 years were the most common age group undergoing surgery (n=991; 81%). A quarter of the procedures were performed on local Tanzanian children seeking care in the camp (n=301; 25%). The most common procedures performed were cesarean sections (n=858; 70%), herniorrhaphies (n=197; 16%), and exploratory laparotomies (n=55; 5%). Refugees were more likely to undergo exploratory laparotomy (n=47; 5%) than Tanzanian children (n=7; 2%; p=0.032). The most common indications for exploratory laparotomy were acute abdomen (n=24; 44%), intestinal obstruction (n=10; 18%), and peritonitis (n=9; 16%). Conclusions There is a significant volume of basic pediatric general surgery performed in the Nyarugusu Camp. Services are used by both refugees and local Tanzanians. We hope this research will inspire further advocacy and research on pediatric surgical services in humanitarian settings worldwide and illuminate the need for including pediatric refugee surgery within the growing global surgery movement.
Collapse
Affiliation(s)
- Sarah Rapaport
- Center for Global Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Zachary Obinna Enumah
- Center for Global Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hilary Ngude
- Tanzania Red Cross Society, Dar es Salaam, Tanzania
| | - Daniel S Rhee
- Center for Global Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Department of Pediatric Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | - Amber Lekey
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Peter J Winch
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Joseph V Sakran
- Center for Global Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Kent A Stevens
- Center for Global Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| |
Collapse
|
17
|
Agoubi LL, Duan N, Rowhani-Rahbar A, Nehra D, Sakran JV, Rivara FP. Patterns in Location of Death From Firearm Injury in the US. JAMA Surg 2023; 158:669-670. [PMID: 37017980 PMCID: PMC10077128 DOI: 10.1001/jamasurg.2022.8380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/12/2022] [Indexed: 04/06/2023]
Abstract
This cross-sectional study assesses non–self-inflicted firearm-related deaths occurring at inpatient or outpatient facilities, hospice care, nursing homes, home, or other settings from 1999 to 2021.
Collapse
Affiliation(s)
- Lauren L. Agoubi
- Department of Surgery, University of Washington School of Medicine, Seattle
- Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Ning Duan
- Harborview Injury Prevention and Research Center, Seattle, Washington
- Firearm Injury and Policy Research Program, University of Washington, Seattle
| | - Ali Rowhani-Rahbar
- Firearm Injury and Policy Research Program, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Deepika Nehra
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Joseph V. Sakran
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia
| | - Frederick P. Rivara
- Harborview Injury Prevention and Research Center, Seattle, Washington
- Firearm Injury and Policy Research Program, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
| |
Collapse
|
18
|
Affiliation(s)
- Rebecca Stone
- Department of Obstetrics and Gynecology, Johns Hopkins University, Baltimore, Maryland
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
| |
Collapse
|
19
|
Sakran JV, Bornstein SS, Dicker R, Rivara FP, Campbell BT, Cunningham RM, Betz M, Hargarten S, Williams A, Horwitz JM, Nehra D, Burstin H, Sheehan K, Dreier FL, James T, Sathya C, Armstrong JH, Rowhani-Rahbar A, Charles S, Goldberg A, Lee LK, Stewart RM, Kerby JD, Turner PL, Bulger EM. Proceedings from the Second Medical Summit on Firearm Injury Prevention, 2022: Creating a Sustainable Healthcare Coalition to Advance a Multidisciplinary Public Health Approach. J Am Coll Surg 2023; 236:1242-1260. [PMID: 36877809 DOI: 10.1097/xcs.0000000000000662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Affiliation(s)
- Joseph V Sakran
- From the American College of Surgeons Committee on Trauma, Chicago, IL (Sakran, Dicker, Cambell, Sathya, Armstrong, Goldberg, Stewart, Kerby, Turner, Bulger)
- Department of Surgery, Johns Hopkins Medicine, Baltimore, MD (Sakran)
| | - Sue S Bornstein
- American College of Physicians, Philadelphia, PA (Bornstein)
| | - Rochelle Dicker
- From the American College of Surgeons Committee on Trauma, Chicago, IL (Sakran, Dicker, Cambell, Sathya, Armstrong, Goldberg, Stewart, Kerby, Turner, Bulger)
- Department of Surgery, University of California Los Angeles, Los Angeles, CA (Dicker)
| | - Frederick P Rivara
- Department of Pediatrics, University of Washington, Seattle, WA (Rivara)
| | - Brendan T Campbell
- From the American College of Surgeons Committee on Trauma, Chicago, IL (Sakran, Dicker, Cambell, Sathya, Armstrong, Goldberg, Stewart, Kerby, Turner, Bulger)
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, CT (Campbell)
| | - Rebecca M Cunningham
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI (Cunningham)
| | - Marian Betz
- Department of Emergency Medicine, University of Colorado, Aurora, CO (Betz)
| | - Stephen Hargarten
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (Hargarten)
| | - Ashley Williams
- Department of Surgery, University of South Alabama, Mobile, AL (Williams)
| | - Joshua M Horwitz
- Johns Hopkins Center for Gun Violence Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Horwitz)
| | - Deepika Nehra
- Department of Surgery, University of Washington, Seattle, WA (Nehra, Bulger)
| | - Helen Burstin
- Council of Medical Specialty Societies, Washington, DC (Burstin)
| | - Karen Sheehan
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (Sheehan)
| | - Fatimah L Dreier
- The Health Alliance for Violence Intervention, Jersey City, NJ (Dreier)
| | - Thea James
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA (James)
| | - Chethan Sathya
- From the American College of Surgeons Committee on Trauma, Chicago, IL (Sakran, Dicker, Cambell, Sathya, Armstrong, Goldberg, Stewart, Kerby, Turner, Bulger)
- Department of Surgery, Cohen Children's Medical Center, Northwell Health, Queens, NY (Sathya)
| | - John H Armstrong
- From the American College of Surgeons Committee on Trauma, Chicago, IL (Sakran, Dicker, Cambell, Sathya, Armstrong, Goldberg, Stewart, Kerby, Turner, Bulger)
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL (Armstrong)
| | - Ali Rowhani-Rahbar
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA (Rowhani-Rahbar)
| | - Scott Charles
- Department of Surgery, Temple University, Philadelphia, PA (Charles, Goldberg)
| | - Amy Goldberg
- From the American College of Surgeons Committee on Trauma, Chicago, IL (Sakran, Dicker, Cambell, Sathya, Armstrong, Goldberg, Stewart, Kerby, Turner, Bulger)
- Department of Surgery, Temple University, Philadelphia, PA (Charles, Goldberg)
| | - Lois K Lee
- Department of Emergency Medicine, Boston Children's Hospital, Boston, MA (Lee)
| | - Ronald M Stewart
- Department of Surgery, University of Texas San Antonio, San Antonio, TX (Stewart)
| | - Jeffrey D Kerby
- From the American College of Surgeons Committee on Trauma, Chicago, IL (Sakran, Dicker, Cambell, Sathya, Armstrong, Goldberg, Stewart, Kerby, Turner, Bulger)
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL (Kerby)
| | - Patricia L Turner
- From the American College of Surgeons Committee on Trauma, Chicago, IL (Sakran, Dicker, Cambell, Sathya, Armstrong, Goldberg, Stewart, Kerby, Turner, Bulger)
| | - Eileen M Bulger
- From the American College of Surgeons Committee on Trauma, Chicago, IL (Sakran, Dicker, Cambell, Sathya, Armstrong, Goldberg, Stewart, Kerby, Turner, Bulger)
- Department of Surgery, University of Washington, Seattle, WA (Nehra, Bulger)
| |
Collapse
|
20
|
Sakran JV. The Roger T. Sherman Lecture: How Health Care Professionals Drive Social Change. Am Surg 2023:31348231175448. [PMID: 37186950 DOI: 10.1177/00031348231175448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- Joseph V Sakran
- Department of Surgery, Johns Hopkins Medicine School of Medicine, Baltimore, MD, USA
| |
Collapse
|
21
|
Sakran JV, Bulger EM. Defining a Roadmap to Firearm Injury Prevention. J Am Coll Surg 2023:00019464-990000000-00636. [PMID: 37125749 DOI: 10.1097/xcs.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
|
22
|
Dobbs JE, Sakran JV. How Green Spaces Can Combat Gun Violence in America. Am J Public Health 2023:e1-e3. [PMID: 37104735 DOI: 10.2105/ajph.2023.307309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- John E Dobbs
- John E. Dobbs is a medical student at The George Washington University, Washington, DC. Joseph V. Sakran is Vice Chair of Clinical Operations, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Joseph V Sakran
- John E. Dobbs is a medical student at The George Washington University, Washington, DC. Joseph V. Sakran is Vice Chair of Clinical Operations, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| |
Collapse
|
23
|
Torres CM, Haut ER, Sakran JV. Error in Variable Conversion in Table. JAMA Surg 2023; 158:562-563. [PMID: 37017982 DOI: 10.1001/jamasurg.2023.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Affiliation(s)
- Crisanto M Torres
- Division of Trauma and Acute Care Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Elliott R Haut
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph V Sakran
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
24
|
Torres CM, Kent A, Scantling D, Joseph B, Haut ER, Sakran JV. Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers. JAMA Surg 2023; 158:532-540. [PMID: 36652255 PMCID: PMC9857728 DOI: 10.1001/jamasurg.2022.6978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance Whole-blood (WB) resuscitation has gained renewed interest among civilian trauma centers. However, there remains insufficient evidence that WB as an adjunct to component therapy-based massive transfusion protocol (WB-MTP) is associated with a survival advantage over MTP alone in adult civilian trauma patients presenting with severe hemorrhage. Objective To assess whether WB-MTP compared with MTP alone is associated with improved survival at 24 hours and 30 days among adult trauma patients presenting with severe hemorrhage. Design, Setting, and Participants This retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2017, and December 31, 2018, included adult trauma patients with a systolic blood pressure less than 90 mm Hg and a shock index greater than 1 who received at least 4 units of red blood cells within the first hour of emergency department (ED) arrival at level I and level II US and Canadian adult civilian trauma centers. Patients with burns, death within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from February 2022 to September 2022. Exposures Resuscitation with WB-MTP compared with MTP alone within 24 hours of ED presentation. Main Outcomes and Measures Primary outcomes were survival at 24 hours and 30 days. Secondary outcomes selected a priori included major complications, hospital length of stay, and intensive care unit length of stay. Results A total of 2785 patients met inclusion criteria: 432 (15.5%) in the WB-MTP group (335 male [78%]; median age, 38 years [IQR, 27-57 years]) and 2353 (84.5%) in the MTP-only group (1822 male [77%]; median age, 38 years [IQR, 27-56 years]). Both groups included severely injured patients (median injury severity score, 28 [IQR, 17-34]; median difference, 1.29 [95% CI, -0.05 to 2.64]). A survival curve demonstrated separation within 5 hours of ED presentation. WB-MTP was associated with improved survival at 24 hours, demonstrating a 37% lower risk of mortality (hazard ratio, 0.63; 95% CI, 0.41-0.96; P = .03). Similarly, the survival benefit associated with WB-MTP remained consistent at 30 days (HR, 0.53; 95% CI, 0.31-0.93; P = .02). Conclusions and Relevance In this cohort study, receipt of WB-MTP was associated with improved survival in trauma patients presenting with severe hemorrhage, with a survival benefit found early after transfusion. The findings from this study are clinically important as this is an essential first step in prioritizing the selection of WB-MTP for trauma patients presenting with severe hemorrhage.
Collapse
Affiliation(s)
- Crisanto M. Torres
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland,Division of Trauma and Acute Care Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Alistair Kent
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Dane Scantling
- Division of Trauma and Acute Care Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Bellal Joseph
- College of Medicine, Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson
| | - Elliott R. Haut
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland,Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph V. Sakran
- Division of Acute Care Surgery, Johns Hopkins Hospital, Baltimore, Maryland,Johns Hopkins School of Medicine, Baltimore, Maryland,Johns Hopkins School of Nursing, Baltimore, Maryland,Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia
| |
Collapse
|
25
|
Lunardi N, Sakran JV. The Importance of Mental Health Services for Children and Adolescents After Firearm-Related Injury. JAMA Surg 2023; 158:35. [PMID: 36322081 DOI: 10.1001/jamasurg.2022.5304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Nicole Lunardi
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas
| | - Joseph V Sakran
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.,Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia
| |
Collapse
|
26
|
Stonko DP, Weller JH, Gonzalez Salazar AJ, Abdou H, Edwards J, Hinson J, Levin S, Byrne JP, Sakran JV, Hicks CW, Haut ER, Morrison JJ, Kent AJ. A Pilot Machine Learning Study Using Trauma Admission Data to Identify Risk for High Length of Stay. Surg Innov 2022:15533506221139965. [PMID: 36397721 DOI: 10.1177/15533506221139965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Trauma patients have diverse resource needs due to variable mechanisms and injury patterns. The aim of this study was to build a tool that uses only data available at time of admission to predict prolonged hospital length of stay (LOS). METHODS Data was collected from the trauma registry at an urban level one adult trauma center and included patients from 1/1/2014 to 3/31/2019. Trauma patients with one or fewer days LOS were excluded. Single layer and deep artificial neural networks were trained to identify patients in the top quartile of LOS and optimized on area under the receiver operator characteristic curve (AUROC). The predictive performance of the model was assessed on a separate test set using binary classification measures of accuracy, precision, and error. RESULTS 2953 admitted trauma patients with more than one-day LOS were included in this study. They were 70% male, 60% white, and averaged 47 years-old (SD: 21). 28% were penetrating trauma. Median length of stay was 5 days (IQR 3-9). For prediction of prolonged LOS, the deep neural network achieved an AUROC of 0.80 (95% CI: 0.786-0.814) specificity was 0.95, sensitivity was 0.32, with an overall accuracy of 0.79. CONCLUSION Machine learning can predict, with excellent specificity, trauma patients who will have prolonged length of stay with only physiologic and demographic data available at the time of admission. These patients may benefit from additional resources with respect to disposition planning at the time of admission.
Collapse
Affiliation(s)
- David P Stonko
- Division of Trauma and Acute Care Surgery, The Johns Hopkins Hospital, 160877The Johns Hopkins Department of Surgery, Baltimore, MD, USA.,137889R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Jennine H Weller
- Division of Trauma and Acute Care Surgery, The Johns Hopkins Hospital, 160877The Johns Hopkins Department of Surgery, Baltimore, MD, USA
| | - Andres J Gonzalez Salazar
- Division of Trauma and Acute Care Surgery, The Johns Hopkins Hospital, 160877The Johns Hopkins Department of Surgery, Baltimore, MD, USA
| | - Hossam Abdou
- 137889R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph Edwards
- 137889R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Jeremiah Hinson
- Department of Emergency Medicine, 1466The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Malone Center for Engineering in Healthcare, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott Levin
- Department of Emergency Medicine, 1466The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Malone Center for Engineering in Healthcare, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James P Byrne
- Division of Trauma and Acute Care Surgery, The Johns Hopkins Hospital, 160877The Johns Hopkins Department of Surgery, Baltimore, MD, USA
| | - Joseph V Sakran
- Division of Trauma and Acute Care Surgery, The Johns Hopkins Hospital, 160877The Johns Hopkins Department of Surgery, Baltimore, MD, USA
| | - Caitlin W Hicks
- Division of Vascular and Endovascular Therapy, 1466The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elliott R Haut
- Division of Trauma and Acute Care Surgery, The Johns Hopkins Hospital, 160877The Johns Hopkins Department of Surgery, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, 1466The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA.,Department of Health Policy and Management, Bloomberg School of Public Health, 1466The Johns Hopkins Baltimore, MD, USA
| | | | - Alistair J Kent
- Division of Trauma and Acute Care Surgery, The Johns Hopkins Hospital, 160877The Johns Hopkins Department of Surgery, Baltimore, MD, USA
| |
Collapse
|
27
|
Enumah ZO, Rafiq MY, Manyama F, Ngude H, Juma O, Sakran JV, Stevens K. Reasons for referral and referral compliance among Congolese and Burundian refugees living in Tanzania: a community-based, cross-sectional survey. BMJ Open 2022; 12:e058778. [PMID: 36192098 PMCID: PMC9535181 DOI: 10.1136/bmjopen-2021-058778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES In order to prevent overburdening of higher levels of care, national healthcare systems rely on processes of referral, including for refugee populations which number 26 million globally. The goal of this study is to use data from a population-based household survey to describe patterns of referral services among a population of Congolese and Burundian refugees living in Tanzania. DESIGN Cross-sectional survey using cluster randomised sampling. SETTING Nyarugusu refugee camp, Kigoma, Tanzania. PARTICIPANTS 153 refugees. PRIMARY OUTCOME Referral compliance. SECONDARY OUTCOMES Proportion of referrals that were surgical; proportion of referrals requiring diagnostic imaging. RESULTS Out of 153 individuals who had been told they needed a referral, 96 (62.7%) had gone to the referral hospital. Of the 57 who had not gone, 36 (63%) reported they were still waiting to go and had waited over a month. Of the participants who had been referred (n=96), almost half of the participants reported they were referred for a surgical problem (n=43, 45%) and the majority received radiological testing at an outside hospital (n=72, 75%). Congolese refugees more frequently had physically completed their referral compared with Burundians (Congolese: n=68, 76.4% vs Burundian: n=28, 43.8%, p<0.001). In terms of intracamp referral networks, most refugees reported being referred to the hospital or clinic by a community health worker (n=133, 86.9%). CONCLUSION To our knowledge, this is the first community-based study on patterns of referral healthcare among refugees in Tanzania and sub-Saharan Africa. Our findings suggest patients were referred for surgical problems and for imaging, however not all referrals were completed in a timely fashion. Future research should attempt to build prospective referral registries that allow for better tracking of patients and examination of waiting times.
Collapse
Affiliation(s)
- Zachary Obinna Enumah
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mohamed Yunus Rafiq
- Department of Anthropology, New York University Shanghai, Shanghai, China
- Ifakara Health Institute, Bagamoyo, Tanzania
| | | | - Hilary Ngude
- Tanzania Red Cross Society, Dar es Salaam, Tanzania
| | - Omar Juma
- Ifakara Health Institute, Bagamoyo, Tanzania
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kent Stevens
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
28
|
Sakran JV, Hargarten S, Rivara FP. Coordinating a National Approach to Violence Prevention. JAMA 2022; 328:1193-1194. [PMID: 36166018 DOI: 10.1001/jama.2022.14076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This Viewpoint discusses violence-related US public health concerns and suggests creating a federal Office of National Violence Prevention to develop a comprehensive, coordinated, and sustained effort to address all aspects of violence in the US.
Collapse
Affiliation(s)
- Joseph V Sakran
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
- Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta, Georgia
| | - Stephen Hargarten
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
- Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee
| | - Frederick P Rivara
- The Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, Departments of Pediatrics and Epidemiology, University of Washington, Seattle
- Editor, JAMA Network Open
| |
Collapse
|
29
|
Sakran JV, Lunardi N. Reducing Firearm Injury and Death in the United States. Adv Surg 2022; 56:49-67. [PMID: 36096577 DOI: 10.1016/j.yasu.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Firearms injury is a major cause of American morbidity and mortality. Although the firearm is a common vector, the intentions with which it is used represent a wide array of social ills-suicide, community violence, domestic violence, mass shootings, legal intervention, and unintended injury. The political and social underpinnings of this epidemic are inseparable from its prevention measures. Surgeons have an important role in firearm policy, research, prehospital and hospital advances, trauma survivor networks, and hospital-based violence prevention programs. It is only through interdisciplinary, multilevel, evidence-based prevention measures that the tides will turn on American firearm injury.
Collapse
Affiliation(s)
- Joseph V Sakran
- Emergency General Surgery, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans Street, Sheikh Zayed Tower / Suite 6107B, Baltimore, MD 21287, USA.
| | - Nicole Lunardi
- Department of Surgery, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9159, USA
| |
Collapse
|
30
|
Enumah ZO, Rafiq MY, Rhee D, Manyama F, Ngude H, Stevens K, Juma O, Sakran JV. Prevalence of pediatric surgical problems among east African refugees: estimates from a cross-sectional survey using random cluster sampling. BMC Pediatr 2022; 22:518. [PMID: 36050745 PMCID: PMC9434863 DOI: 10.1186/s12887-022-03576-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 05/10/2022] [Indexed: 11/10/2022] Open
Abstract
IMPORTANCE Surgery is a foundational aspect to high functioning health care systems. In the wake of the Lancet Commission on Global Surgery, previous research has focused on defining the burden of surgical conditions among a pediatric population, however these studies often fail to include forced migrant or refugees. The goal of this study was to estimate the prevalence of pediatric surgical conditions among refugees in east Africa. METHODS We used the previously validated Surgeons OverSeas Assessment of Surgical Need (SOSAS) that utilizes cross-sectional design with random cluster sampling to assess prevalence of surgical disease among participants aged 0 to 18 years in Nyarugusu refugee camp, Tanzania. We used descriptive and multivariable analyses including an average marginal effects model. RESULTS A total of 1,658 participants were included in the study. The mean age of our sample was 8.3 ± 5.8 years. A total of 841 participants (50.7%) were male and 817 participants (49.3%) were female. A total of 513 (n = 30.9%) reported a history or presence of a problem that may be surgical in nature, and 280 (54.6%) of them reported the problem was ongoing or untreated. Overall, 16.9% had an ongoing problem that may be amenable to surgery. We found that increasing age and recent illness were associated with having a surgical problem on both our multivariable analyses. CONCLUSION To our knowledge, this is the first and largest study of prevalence of surgical conditions among refugee children in sub-Saharan Africa. We found that over 16% (one-in-six) of refugee children have a problem that may be amenable to surgery. Our results provide a benchmark upon which other studies in conflict or post-conflict zones with refugee or forced migrant populations may be compared.
Collapse
Affiliation(s)
- Zachary Obinna Enumah
- Department of Surgery, Johns Hopkins Global Surgery Initiative (JHGSI), Johns Hopkins Hospital, Tower 110 Doctor's Lounge, 600 N. Wolfe Street, Baltimore, MD, 21287, USA. .,Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA.
| | - Mohamed Yunus Rafiq
- Department of Anthropology, New York University Shanghai, Shanghai, China.,Ifakara Health Institute, Bagamoyo, Tanzania
| | - Daniel Rhee
- Department of Surgery, Johns Hopkins Global Surgery Initiative (JHGSI), Johns Hopkins Hospital, Tower 110 Doctor's Lounge, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | | | - Hilary Ngude
- Tanzania Red Cross Society, Dar es Salaam, Tanzania
| | - Kent Stevens
- Department of Surgery, Johns Hopkins Global Surgery Initiative (JHGSI), Johns Hopkins Hospital, Tower 110 Doctor's Lounge, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.,Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Omar Juma
- Ifakara Health Institute, Bagamoyo, Tanzania
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins Global Surgery Initiative (JHGSI), Johns Hopkins Hospital, Tower 110 Doctor's Lounge, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| |
Collapse
|
31
|
Richard Holt G, Benjamin GC, C Grossman D, O’Toole ME, Sakran JV. Gun Violence and Mass Shootings as a Public Health Priority in the United States: An Expert Panel Discussion. Perm J 2022; 26:6-19. [DOI: 10.7812/tpp/22.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- G Richard Holt
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | | | | | - Joseph V Sakran
- Morehouse School of Medicine and Johns Hopkins Department of Surgery, Baltimore, MD, USA
| |
Collapse
|
32
|
Marwaha JS, Lunardi N, Sakran JV. Real-world Data-A Key Barrier to Building Out the Science of Firearm Safety. JAMA Surg 2022; 157:369-370. [PMID: 35262632 DOI: 10.1001/jamasurg.2022.0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jayson S Marwaha
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Nicole Lunardi
- Department of Surgery, University of Texas Southwestern, Dallas
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
33
|
Enumah ZO, Manyama F, Yenokyan G, Ngude H, Rafiq MY, Juma O, Stevens K, Sakran JV. Untreated Surgical Problems Among East African Refugees: A Cluster Randomized, Cross-Sectional Study. World J Surg 2022; 46:1278-1287. [DOI: 10.1007/s00268-022-06505-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2022] [Indexed: 01/12/2023]
|
34
|
Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
Collapse
Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
| |
Collapse
|
35
|
Maurer LR, Sakran JV, Kaafarani HM. Predicting and Communicating Geriatric Trauma Outcomes. Curr Trauma Rep 2021. [DOI: 10.1007/s40719-020-00209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
36
|
Kuy S, Tsai R, Bhatt J, Chu QD, Gandhi P, Gupta R, Gupta R, Hole MK, Hsu BS, Hughes LS, Jarvis L, Jha SS, Annamalai A, Kotwal M, Sakran JV, Vohra S, Henry TL, Correa R. Focusing on Vulnerable Populations During COVID-19. Acad Med 2020; 95:e2-e3. [PMID: 32639264 PMCID: PMC7363379 DOI: 10.1097/acm.0000000000003571] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- SreyRam Kuy
- Assistant professor, Department of Surgery, Baylor College of Medicine, Houston, Texas;
| | - Raymond Tsai
- Assistant clinical professor, Department of Family Medicine, University of California, San Francisco, San Francisco, California
| | - Jay Bhatt
- Internist, geriatrician, and former Chief Medical Officer, American Hospital Association, Chicago, Illinois
| | - Quyen D Chu
- Chief, Division of Surgical Oncology, and Edward & Freda Green Professor in Surgical Oncology, Department of Surgery, LSU-Health Sciences Center-Shreveport, Shreveport, Louisiana
| | - Pritesh Gandhi
- Associate chief medical officer, People's Community Clinic, Austin, Texas
| | - Rohit Gupta
- Medical student, Baylor College of Medicine, Houston, Texas
| | - Reshma Gupta
- Medical director of population care and value, Department of Internal Medicine, University of California, Davis, Sacramento, California
| | - Michael K Hole
- Assistant professor of pediatrics, population health, and public policy, Department of Pediatrics, The University of Texas at Austin, Austin, Texas
| | - Benson S Hsu
- Associate professor of pediatrics, Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Lauren S Hughes
- Director, Farley Health Policy Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lenore Jarvis
- Clinical assistant professor of pediatrics, The George Washington University School of Medicine and Health Sciences, and Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - Sachin Sunny Jha
- Assistant clinical professor, Department of Anesthesiology, University of Southern California, Los Angeles, California
| | | | - Mansi Kotwal
- Clinical assistant professor of pediatrics, The George Washington University School of Medicine and Health Sciences, and Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - Joseph V Sakran
- Director, Emergency General Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sameer Vohra
- Chair, Department of Population Science and Policy, and assistant professor of pediatrics, medical humanities, and law, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Tracey L Henry
- Assistant health director, Grady Primary Care Center, and assistant professor, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ricardo Correa
- Program director, Endocrinology, Diabetes, and Metabolism Fellowship, University of Arizona College of Medicine-Phoenix, and Phoenix Veterans Affairs Medical Center, Phoenix, Arizona
| |
Collapse
|
37
|
Boyarsky BJ, Jackson KR, Kernodle AB, Sakran JV, Garonzik-Wang JM, Segev DL, Ottmann SE. Estimating the potential pool of uncontrolled DCD donors in the United States. Am J Transplant 2020; 20:2842-2846. [PMID: 32372460 DOI: 10.1111/ajt.15981] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/10/2020] [Accepted: 04/27/2020] [Indexed: 01/25/2023]
Abstract
Organs from uncontrolled DCD donors (uDCDs) have expanded donation in Europe since the 1980s, but are seldom used in the United States. Cited barriers include lack of knowledge about the potential donor pool, lack of robust outcomes data, lack of standard donor eligibility criteria and preservation methods, and logistical and ethical challenges. To determine whether it would be appropriate to invest in addressing these barriers and building this practice, we sought to enumerate the potential pool of uDCD donors. Using data from the Nationwide Emergency Department Sample, the largest all-payer emergency department (ED) database, between 2013 and 2016, we identified patients who had refractory cardiac arrest in the ED. We excluded patients with contraindications to both deceased donation (including infection, malignancy, cardiopulmonary disease) and uDCD (including hemorrhage, major polytrauma, burns, and poisoning). We identified 9828 (range: 9454-10 202) potential uDCDs/y; average age was 32 years, and all were free of major comorbidity. Of these, 91.1% had traumatic deaths, with major causes including nonhead blunt injuries (43.2%) and head injuries (40.1%). In the current era, uDCD donors represent a significant potential source of unused organs. Efforts to address barriers to uDCD in the United States should be encouraged.
Collapse
Affiliation(s)
- Brian J Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amber B Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shane E Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
38
|
Leeds IL, Jones C, DiBrito SR, Sakran JV, Haut ER, Kent AJ. Delay in emergency hernia surgery is associated with worse outcomes. Surg Endosc 2020; 34:4562-4573. [PMID: 31741158 PMCID: PMC8710144 DOI: 10.1007/s00464-019-07245-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/28/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients requiring emergent surgery for hernia vary widely in presentation and management. The purpose of this study was to determine if the variation in timing of urgent surgery impacts surgical outcomes. METHODS The national NSQIP database for years 2011-2016 was queried for emergent surgeries for abdominal hernia resulting in obstruction or gangrene by primary post-op diagnosis. Diaphragmatic hernias were excluded. Patients were grouped by surgical timing from admission to day of surgery: same day, next day, and longer delay. Multinomial propensity score weighting was used to address potential differences in underlying covariates' clustering across the timing groups followed by multivariable logistic regression of morbidity and mortality. RESULTS Weighted analysis yielded an effective sample size of 76,364. Hernia types included inguinal (20.9%); femoral (6.7%); umbilical (20.2%); ventral (41.0%); and other (10.4%). Delayed surgery was associated with increased rates of major complications (26.4% vs. 20.9%, p < 0.001), longer operative times (+ 12.5 min, p < 0.001), longer postoperative lengths of stay (+ 1.6 days, p < 0.001), increased re-operations (5.9% vs. 4.7%, p = 0.019), increased readmissions (7.0% vs. 5.7%, p = 0.004), and increased 30-day mortality (2.4% vs. 1.7%, p = 0.002). When controlling for other factors, next-day surgery (OR 1.23, 95% CI 1.05-1.45, p = 0.009) and surgery delayed more than one day (OR 1.40, 95% CI 1.13-1.73, p < 0.002) were associated with an increased odds of a major complication. Mortality and readmission by timing of surgery were not independently significant. CONCLUSIONS Delay in surgery for emergent hernias increased the odds of major morbidity but not mortality. Patients presenting with hernia and an indication for urgent surgical intervention may benefit from an operation as soon as feasible rather than warrant waiting for further physiologic optimization, medical clearance, or specialized surgical personnel.
Collapse
Affiliation(s)
- Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6103, Baltimore, MD, 21287, USA
| | - Christian Jones
- Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6103, Baltimore, MD, 21287, USA
| | - Sandra R DiBrito
- Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6103, Baltimore, MD, 21287, USA
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6103, Baltimore, MD, 21287, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6103, Baltimore, MD, 21287, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Alistair J Kent
- Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6103, Baltimore, MD, 21287, USA.
| |
Collapse
|
39
|
Sakran JV, Mehta A, Matar MM, Wilson DA, Kent AJ, Anton RF, Fakhry SM. The Utility of Carbohydrate-Deficient Transferrin in Identifying Chronic Alcohol Users in the Injured Patient: Expanding the Toolkit. J Surg Res 2020; 257:92-100. [PMID: 32818790 DOI: 10.1016/j.jss.2020.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/21/2020] [Accepted: 07/17/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Alcohol use remains abundant in patients with traumatic injury. Previous studies have suggested that serum carbohydrate-deficient transferrin (%dCDT) levels, relative to blood alcohol levels (BALs), may better differentiate episodic binge drinkers from sustained heavy consumers in admitted patients with traumatic injury. We characterized %dCDT levels and BAL levels to differentiate binge drinkers from sustained heavy consumers in admitted trauma patients and their associations with outcomes. METHODS This prospective, cross-sectional, observational study assessed %dCDT and BAL levels in admitted male and female patients with traumatic injury (≥18 y) at an American College of Surgeons Committee on Trauma level-1 center from July 2014 to June 2016. We designated patients with %dCDT levels ≥1.7% (CDT+) as chronic alcohol users and dichotomized acutely intoxicated patients using three different BAL-level thresholds. Primary outcomes included in-hospital complications, along with prolonged ventilation and intensive care unit length of stay, both defined as the top decile. Secondary outcomes included rates of drug or alcohol withdrawal and all-cause mortality. Analyses were adjusted for clinical factors. RESULTS We studied 715 patients (77.5% men, 60.6% ≤ 40 y of age, median Injury Severity Score: 14, 41.7% motor vehicle crashes, 17.9% gunshot wounds, 11.1% falls). While 31.0% were CDT+, 48.7% were BAL>0. After adjusting for CDT levels, BAL levels >0, >100, or >200 were not associated with adverse outcomes. However, CDT+ relative to patients with CDT were associated with complications (adjusted odds ratio: 1.96 [1.24-3.09]), prolonged ventilation days (3.23 [1.08-9.65]), and prolonged intensive care unit stays (2.83 [1.20-6.68]). CONCLUSIONS In this 2-year prospective, cross-sectional, and observational study, we found that %dCDT levels, relative to BAL levels, may better stratify admitted patients with traumatic injury into acute versus chronic alcohol users, identifying those at higher risk for in-hospital complications.
Collapse
Affiliation(s)
- Joseph V Sakran
- Johns Hopkins Hospital, Department of Surgery, Baltimore, Maryland.
| | - Ambar Mehta
- Johns Hopkins University, School of Medicine, Baltimore, Maryland; NewYork-Presbyterian, Columbia University Medical Center, Department of Surgery, New York, New York
| | - Maher M Matar
- The Ottawa Hospital, Department of Surgery, Ottawa, Ontario, Canada
| | - Dulaney A Wilson
- Medical University of South Carolina, Department of Surgery, Charleston, South Carolina
| | - Alistair J Kent
- Johns Hopkins Hospital, Department of Surgery, Baltimore, Maryland
| | - Raymond F Anton
- Medical University of South Carolina, Department of Surgery, Charleston, South Carolina; Charleston Alcohol Research Center, Charleston, South Carolina
| | - Samir M Fakhry
- Reston Hospital Center, Department of Surgery, Reston, Virginia
| |
Collapse
|
40
|
Sakran JV, Ezzeddine H, Schwab CW, Bonne S, Brasel KJ, Burd RS, Cuschieri J, Ficke J, Gaines BA, Giacino JT, Gibran NS, Haider A, Hall EC, Herrera-Escobar JP, Joseph B, Kao L, Kurowski BG, Livingston D, Mandell SP, Nehra D, Sarani B, Seamon M, Yonclas P, Zarzaur B, Stewart R, Bulger E, Nathens AB. Proceedings from the Consensus Conference on Trauma Patient-Reported Outcome Measures. J Am Coll Surg 2020; 230:819-835. [PMID: 32201197 DOI: 10.1016/j.jamcollsurg.2020.01.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Joseph V Sakran
- Division of Acute Care Surgery, Departments of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Hiba Ezzeddine
- Division of Acute Care Surgery, Departments of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C William Schwab
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia
| | - Stephanie Bonne
- Division of Trauma, Department of Surgery, New Jersey Medical School Rutgers, Newark, NJ
| | - Karen J Brasel
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health Sciences University, Portland, OR
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Department of Surgery, Children's National Medical Center, Washington, DC
| | - Joseph Cuschieri
- Divisions of Trauma, Burn, and Critical Care, Division of Trauma, Burn
| | - James Ficke
- Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Barbara A Gaines
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joseph T Giacino
- Division of Rehabilitation Neuropsychology, Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, Charlestown
| | - Nicole S Gibran
- Division of Restorative Burn Surgery, Division of Trauma, Burn
| | - Adil Haider
- Medical College in Pakistan, The Aga Khan University, Karachi, Pakistan
| | - Erin C Hall
- MedStar Washington Hospital Center, Washington, DC; Department of Surgery, Washington, DC
| | - Juan P Herrera-Escobar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Bellal Joseph
- Division of Trauma, Acute Care, Burn and Emergency Surgery, Department of Surgery, the University of Arizona College of Medicine, Tucson, AZ
| | - Lillian Kao
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Brad G Kurowski
- Division of Physical Medicine and Rehabilitation, Cincinnati Children's Hospital Medical Center; Department of Pediatrics and Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David Livingston
- Division of Trauma, Department of Surgery, New Jersey Medical School Rutgers, Newark, NJ
| | - Samuel P Mandell
- Divisions of Trauma, Burn, and Critical Care, Division of Trauma, Burn
| | - Deepika Nehra
- Divisions of Trauma, Burn, and Critical Care, Division of Trauma, Burn
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery (Sarani), Georgetown University School of Medicine, Washington, DC
| | - Mark Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia
| | - Peter Yonclas
- Division of Trauma, Department of Surgery, New Jersey Medical School Rutgers, Newark, NJ
| | - Ben Zarzaur
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin School of Medicine, Madison, WI
| | - Ronald Stewart
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX; Committee on Trauma, Chicago, IL
| | - Eileen Bulger
- Critical Care, Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA; Committee on Trauma, Chicago, IL
| | - Avery B Nathens
- American College of Surgeons; Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | |
Collapse
|
41
|
Joseph B, Zeeshan M, Sakran JV, Hamidi M, Kulvatunyou N, Khan M, O'Keeffe T, Rhee P. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. JAMA Surg 2020; 154:500-508. [PMID: 30892574 DOI: 10.1001/jamasurg.2019.0096] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The need for improved methods of hemorrhage control and resuscitation has resulted in a reappraisal of resuscitative endovascular balloon occlusion of the aorta (REBOA). However, there is a paucity of data regarding the use of REBOA on a multi-institutional level in the United States. Objective To evaluate the outcomes in trauma patients after REBOA placement. Design, Setting, and Participants A case-control retrospective analysis was performed of the 2015-2016 American College of Surgeons Trauma Quality Improvement Program data set, a national multi-institutional database of trauma patients in the United States. A total of 593 818 adult trauma patients (aged ≥18 years) were analyzed and 420 patients were matched and included in the study; patients who were dead on arrival or were transferred from other facilities were excluded. Trauma patients who underwent REBOA placement in the ED were identified and matched with a similar cohort of patients (the no-REBOA group). Both groups were matched in a 1:2 ratio using propensity score matching for demographics, vital signs, mechanism of injury, injury severity score, head abbreviated injury scale score, each body region abbreviated injury scale score, pelvic fractures, lower extremity vascular injuries and fractures, and number and grades of intra-abdominal solid organ injuries. Main Outcomes and Measures Outcome measures were the rates of complications and mortality. Results Of 593 818 trauma patients, 420 patients (the REBOA group, 140 patients; 36 women and 104 men; mean [SD] age, 44 [20] years; the no-REBOA group, 280 patients; 77 women and 203 men; mean [SD] age, 43 [19] years) were matched and included in the analysis. Among the REBOA group, median injury severity score was 29 (interquartile range [IQR], 18-38) and 129 patients (92.1%) had a blunt mechanism of injury. There was no significant difference between groups in median 4-hour blood transfusion (REBOA: packed red blood cells, 6 U [IQR, 3-8 U]; platelets, 4 U [IQR, 3-9 U], and plasma, 3 U [IQR, 2-5 U]; and no-REBOA: packed red blood cells, 7 U [IQR, 3-9 U]; platelets, 4 U [IQR, 3-8 U], and plasma, 3 U [IQR, 2-6 U]) or 24-hour blood transfusion (REBOA: packed red blood cells, 9 U [IQR, 5-20 U]; platelets, 7 U [IQR, 3-13 U], and plasma, 9 U [IQR, 6-20 U]; and no-REBOA: packed red blood cells, 10 U [IQR, 4-21 U]; platelets, 8 U [IQR, 3-12 U], and plasma, 10 U [IQR, 7-20 U]), median hospital length of stay (REBOA, 8 days [IQR, 1-20 days]; and no-REBOA, 10 days [IQR, 5-22 days]), or median intensive care unit length of stay (REBOA, 5 days [IQR, 2-14 days]; and no-REBOA, 6 days [IQR, 3-15 days]). The mortality rate was higher in the REBOA group as compared with the no-REBOA group (50 [35.7%] vs 53 [18.9%]; P = .01). Patients who underwent REBOA placement were also more likely to develop acute kidney injury (15 [10.7%] vs 9 [3.2%]; P = .02) and more likely to undergo lower extremity amputation (5 [3.6%] vs 2 [0.7%]; P = .04). Conclusions and Relevance Placement of REBOA in severely injured trauma patients was associated with a higher mortality rate compared with a similar cohort of patients with no placement of REBOA. Patients in the REBOA group also had higher rates of acute kidney injury and lower leg amputations. There is a need for a concerted effort to clearly define when and in which patient population REBOA has benefit.
Collapse
Affiliation(s)
- Bellal Joseph
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson
| | - Joseph V Sakran
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Mohammad Hamidi
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson
| | - Muhammad Khan
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson
| | - Terence O'Keeffe
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson
| | - Peter Rhee
- Division of Acute Care Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
42
|
Affiliation(s)
- Rachel L Choron
- Rachel L. Choron and Joseph V. Sakran are with the Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph V Sakran
- Rachel L. Choron and Joseph V. Sakran are with the Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
43
|
Affiliation(s)
- Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Fasika Woreta
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
44
|
Abstract
Importance Studies show that secondary overtriage (SO) contributes significantly to the economic burden of injured patients; thus, the association of SO with use of the trauma system has been examined. However, the association of the underlying trauma system design with such overtriage has yet to be evaluated. Objectives To evaluate whether the distribution of trauma centers in a statewide trauma system is associated with SO and to identify clinical and demographic factors that may lead to SO. Design, Setting, and Participants A retrospective cohort study was performed using 2008-2012 data from the Ohio Trauma and Emergency Medical Services registries. All patients taken to level III or nontrauma centers from the scene of the injury with an Injury Severity Score less than 15 and discharged alive were included. Among these patients, those with SO were identified as those who were subsequently transferred to a level I or II trauma center, had no surgical intervention, and were discharged alive within 48 hours of admission. The SO group was analyzed descriptively. Multiple logistic regression was used to identify system-level factors associated with SO. Statistical analysis was performed from August 1, 2017, to January 31, 2018. Main Outcomes and Measures The primary outcome was the occurrence of SO. Results Of 34 494 trauma patients able to be matched in the 2 registries, 7881 (22.9%) met the inclusion criteria, of whom 965 (12.2%) had SO. The median age in the SO group was 40 years (interquartile range, 26-55 years), with 299 women and 666 men. After adjusting for age, sex, comorbidities, injury type, and insurance status, the study found that system-level factors (number of level I or II trauma centers in the region [>1]) were significantly associated with SO (adjusted odds ratio, 1.98; 95% CI, 1.64-2.38; P < .001; area under the curve, 0.89). The reasons for choice of destination by emergency medical services (specifically, choosing the closest facility: adjusted odds ratio, 1.65; 95% CI, 1.37-1.98; P < .001) and use of a field trauma triage protocol (adjusted odds ratio, 2.21; 95% CI, 1.70-2.87; P < .001), significantly increased the likelihood of SO. Conclusions and Relevance This study's findings suggest that the distribution of major trauma centers in the region is significantly associated with SO. Subsequent investigation to identify the optimal number and distribution of trauma centers may therefore be critical. Specific outreach and collaboration of level III trauma centers and nontrauma centers with level I and II trauma centers, along with the use of telemedicine, may provide further guidance to level III trauma centers and nontrauma centers on when to transfer injured patients.
Collapse
Affiliation(s)
- Priti P Parikh
- Department of Surgery, Wright State University, Dayton, Ohio
| | - Pratik Parikh
- Department of Surgery, Wright State University, Dayton, Ohio.,Department of Biomedical, Industrial, and Human Factors Engineering, Wright State University, Dayton, Ohio
| | - Logan Mamer
- Department of Biomedical, Industrial, and Human Factors Engineering, Wright State University, Dayton, Ohio
| | - Mary C McCarthy
- Department of Surgery, Wright State University, Dayton, Ohio
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
45
|
Affiliation(s)
- Rachel L Choron
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins Hospital, 1800 Orleans Street, Sheikh Zayed Tower, Suite 6107, Baltimore, MD 21287, USA
| | - Sarabeth Spitzer
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - Joseph V Sakran
- Department of Surgery, The Johns Hopkins University School of Medicine, Emergency General Surgery, The Johns Hopkins Hospital, 1800 Orleans Street, Sheikh Zayed Tower, Suite 6107, Baltimore, MD 21287, USA.
| |
Collapse
|
46
|
Yeh DD, Martin M, Sakran JV, Meier K, Mendoza A, Grant AA, Parks J, Byerly S, Lee EE, McKinley WI, McClave SA, Miller K, Mazuski J, Taylor B, Luckhurst C, Fagenholz P. Advances in nutrition for the surgical patient. Curr Probl Surg 2019; 56:343-398. [DOI: 10.1067/j.cpsurg.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
47
|
Yeh DD, Martin M, Sakran JV, Meier K, Mendoza A, Grant A, Parks J, Byerly S, Lee E, McKinley WI, McClave SA, Miller K, Mazuski J, Taylor B, Luckhurst C, Fagenholz P. In Brief. Curr Probl Surg 2019. [DOI: 10.1067/j.cpsurg.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
48
|
Albaghdadi A, Leeds IL, Florecki KL, Canner JK, Schneider EB, Sakran JV, Haut ER. Variation in the use of MRI for cervical spine clearance: an opportunity to simultaneously improve clinical care and decrease cost. Trauma Surg Acute Care Open 2019; 4:e000336. [PMID: 31392284 PMCID: PMC6660802 DOI: 10.1136/tsaco-2019-000336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 06/07/2019] [Indexed: 12/03/2022] Open
Abstract
Background For years, controversy has existed about the ideal approach for cervical spine clearance in obtunded, blunt trauma patients. However, recent national guidelines suggest that MRI is not necessary for collar clearance in these patients. The purpose of this study was to identify the extent of national variation in the use of MRI and assess patient-specific and hospital-specific factors associated with the practice. Methods We performed a retrospective review of the National Trauma Data Bank from 2007 to 2012. We included blunt trauma patients aged ≥18 years, admitted to level 1 or 2 trauma centers (TCs), with a Glasgow Coma Scale <8, Abbreviated Injury Scale >3 for the head and mechanically ventilated for more than 72 hours. Multilevel modeling was used to identify patient-level and hospital-level factors associated with spine MRI use. Results 32 125 obtunded, blunt trauma patients treated at 395 unique TCs met our inclusion criteria. The mean proportion of patients who received MRI over the entire sample was 9.9%. The proportions of patients at each hospital who received a spine MRI ranged from 0.5% to 68.7%. Younger patients, with injuries from motor vehicle collisions and pedestrian injuries, were more likely to receive MRI. When controlling for other variables, Injury Severity Score (ISS) was not associated with MRI use. Hospitals in the Northeast, level 1 TCs and non-teaching hospitals were more likely to obtain MRIs in this patient population. Conclusion After controlling for patient-level characteristics, variation remained in MRI use based on geography, trauma center level and teaching status. This evidence suggests that current national guidelines limiting the use of MRI for cervical spine evaluation following blunt trauma are not being followed consistently. This may be due to physicians not being up to date with best practice care, unavailability of locally adopted protocols in institutions or lack of consensus among clinical providers. Level of evidence Prognostic and epidemiological, level III.
Collapse
Affiliation(s)
- Alia Albaghdadi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Joseph K Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eric B Schneider
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
49
|
Yeh DD, Sakran JV, Rattan R, Mehta A, Ruiz G, Lieberman H, Mulder M, Namias N, Zakrison T, Pust GD. A survey of the practice and attitudes of surgeons regarding the treatment of appendicitis. Am J Surg 2019; 218:106-112. [PMID: 30193740 DOI: 10.1016/j.amjsurg.2018.08.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/22/2018] [Accepted: 08/25/2018] [Indexed: 11/28/2022]
|
50
|
Bell N, Arrington A, Adams SA, Jones M, Sakran JV, Mehta A, Eberth JM. Incidental Cancer Diagnoses in Trauma Patients: A Case-Control Study Evaluating Long-term Outcomes. J Surg Res 2019; 242:304-311. [PMID: 31128411 DOI: 10.1016/j.jss.2019.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/02/2019] [Accepted: 03/06/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study evaluates whether trauma patients who incidentally learned about a malignancy have similar long-term outcomes as patients who organically learned about their malignancy. MATERIALS AND METHODS Incidental findings (IF) patients were matched to noninjured cancer controls on age group, sex, cancer site, stage, and year of diagnosis. Unadjusted covariates included race, insurance type, rural residence, and time from diagnosis to first cancer intervention. Cox proportional hazard regression models were used to measure adjusted all-cause and cancer-specific mortality risk. RESULTS Adjusted long-term mortality risk among IF cases was 1.42 (95% confidence interval [1.11-1.81]) compared with noninjured cancer controls. There was no statistically significant difference in all-cause mortality among IF cases who survived at least 30 d (1.24 [0.88-1.74]). IF cases had no increased risk of cancer-related mortality compared with controls (1.26 [0.96-1.64]). CONCLUSIONS Long-term mortality risks among trauma patients with incidental cancer diagnoses are no different than the cancer population as a whole among patients who survive at least 30 d after injury. IF trauma patients are not more susceptible to cancer-related causes of death as a result of a physiological stress response due to injury.
Collapse
Affiliation(s)
- Nathaniel Bell
- College of Nursing, University of South Carolina, Columbia, South Carolina.
| | | | - Swann Arp Adams
- College of Nursing, University of South Carolina, Columbia, South Carolina
| | - Mark Jones
- Department of Surgery, University of South Carolina, Columbia, South Carolina
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ambar Mehta
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Jan M Eberth
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| |
Collapse
|