Pediatric Acute Compartment Syndrome in Long Bone Fractures: Who is at Risk?

INTRODUCTION

There is a paucity of large-scale data on the factors that suggest an impending or underlying extremity pediatric acute compartment syndrome (ACS). In addition, literature regarding the timing of operative fixation and the risk of ACS is mixed. We aimed to describe the factors associated with pediatric ACS.

METHODS

Analysis of 2017-2019 Trauma Quality Improvement Program. We included patients aged <18 y diagnosed with upper extremity (UE) and lower extremity (LE) fractures. Burns and insect bites/stings were excluded. Multivariable regression analyses were performed to identify the predictors of ACS.

RESULTS

61,537 had LE fractures, of which 0.5% developed ACS. 76,216 had UE fractures, of which 0.16% developed ACS. Multivariable regression analyses identified increasing age, male gender, motorcycle collision, and pedestrian struck mechanisms of injury, comminuted and open fractures, tibial and concurrent tibial and fibular fractures, forearm fractures, and operative fixation as predictors of ACS (P value <0.05). Among LE fractures, 34% underwent open reduction internal fixation (time to operation = 14 [8-20] hours), and 2.1% underwent ExFix (time to operation = 9 [4-17] hours). Among UE fractures, 54% underwent open reduction internal fixation (time to operation = 11 [6-16] hours), and 1.9% underwent ExFix (time to operation = 9 [4-14] hours). Every hour delay in operative fixation of UE and LE fractures was associated with a 0.4% increase in the adjusted odds of ACS (P value <0.05).

CONCLUSIONS

Our results may aid clinicians in recognizing children who are "at risk" for ACS. Future studies are warranted to explore the optimal timing for the operative fixation of long bone fractures to minimize the risk of pediatric ACS.

The Importance of Circulation in Airway Management: Preventing Post-Intubation Hypotension in The Trauma Bay

OBJECTIVE

To identify the modifiable and non-modifiable risk factors associated with post-intubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay.

SUMMARY BACKGROUND DATA

ETI has been associated with hemodynamic instability, termed PIH, yet its risk factors in trauma patients remain under-investigated.

METHODS

This is a prospective observational study at a level I trauma center over 4 years (2019-2022). All adult (≥18) trauma patients requiring ETI in the trauma bay were included. Blood pressure was monitored both pre- and post-intubation. Multivariable logistic regression analysis was performed to identify the modifiable and non-modifiable factors associated with PIH.

RESULTS

708 patients required ETI in the trauma bay, of which, 435 (61.4%) developed PIH. The mean (SD) age was 43 (21) and 71% were male. Median [IQR] arrival GCS was 7 [3-13]. Patients who developed PIH had a lower mean (SD) pre-intubation SBP (118 (46) vs. 138 (28), P<0.001) and higher median [IQR] ISS (27 [21-38] vs. 21 [9-26], P<0.001). Multivariable regression analysis identified BMI>25, increasing ISS, penetrating injury, spinal cord injury, Pre-intubation PRBC requirements, and diabetes mellitus as non-modifiable risk factors associated with increased odds of PIH. In contrast, pre-intubation administration of 3% hypertonic saline and vasopressors were identified as the modifiable factors significantly associated with reduced PIH.

CONCLUSION

More than half of the patients requiring ETI in the trauma bay developed PIH. This study identified modifiable and non-modifiable risk factors that influence the development of PIH, which will help physicians when considering ETI upon patient arrival.

LEVEL OF EVIDENCE

Level III, Prognostic Study.

Defining the Problem: 53 Years of Firearm Violence Afflicting America's Schools

BACKGROUND

Firearm violence and school shootings remain a significant public health problem. This study aimed to examine how publicly available data from all 50 states might improve our understanding of the situation, firearm type, and demographics surrounding school shootings.

STUDY DESIGN

School shootings occurring in the US for 53 years ending in May 2022 were analyzed, using primary data files that were obtained from the Center for Homeland Defense and Security. Data analyzed included situation, injury, firearm type, and demographics of victims and shooters. We compared the ratio of fatalities per wounded after stratifying by type of weapon. Rates (among children) of school shooting victims, wounded, and fatalities per 1 million population were stratified by year and compared over time.

RESULTS

A total of 2,056 school shooting incidents involving 3,083 victims were analyzed: 2,033 children, 5 to 17 years, and 1,050 adults, 18 to 74 years. Most victims (77%) and shooters (96%) were male individuals with a mean age of 18 and 19 years, respectively. Of the weapons identified, handguns, rifles, and shotguns accounted for 84%, 7%, and 4%, respectively. Rifles had a higher fatality-to-wounded ratio (0.45) compared with shooters using multiple weapons (0.41), handguns (0.35), and shotguns (0.30). Linear regression analysis identified a significant increase in the rate of school shooting victims (β = 0.02, p = 0.0003), wounded (β = 0.01, p = 0.026), and fatalities (β = 0.01, p = 0.0003) among children over time.

CONCLUSIONS

Despite heightened public awareness, the incidence of school shooting victims, wounded, and fatalities among children has steadily and significantly increased over the past 53 years. Understanding the epidemic represents the first step in preventing continued firearm violence in our schools.

Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen

INTRODUCTION

Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen.

METHODS

In this analysis of 2017-2021 American College of Surgeons-Trauma Quality Improvement Program (ACS TQIP), adult(≥18 y) patients with SUD and positive drug screen who survived the hospital admission were included. Outcomes measure was the receipt of MHS. Poisson regression analysis with clustering by facility was performed to identify independent predictors of receipt of MHS.

RESULTS

128,831 patients were identified of which 3.4% received MHS. Mean age was 41 y, 76% were male, 63% were White, 25% were Black, 12% were Hispanic, and 82% were insured. Median injury severity score was 9, and 54% were managed at an ACS level I trauma center. On regression analysis, female gender (aOR = 1.17, 95% CI = 1.09-1.25), age ≥65 y (aOR = 0.98, 95% CI = 0.97-0.99), White race (aOR = 1.37, 95% CI = 1.28-1.47), Hispanic ethnicity (aOR = 0.84, 95% CI = 0.76-0.93), insured status (aOR = 1.22, 95% CI = 1.13-1.33), and management at ACS level I trauma centers (aOR = 1.47, 95% CI = 1.38-1.57) were independent predictors of receipt of MHS.

CONCLUSIONS

Race, ethnicity, and socioeconomic factors predict the receipt of MHS in trauma patients with SUD and positive drug screens. It is unknown if these disparities affect the long-term outcomes of these vulnerable patients. Further research is warranted to expand on the contributing factors leading to these disparities and possible strategies to address them.

Impact of Patient and Procedural Factors on Outcomes Following Mesenteric Bypass

BACKGROUND

Mesenteric bypass (MB) for patients with acute (AMI) and chronic mesenteric ischemia (CMI) is associated with cardiovascular (CV) and pulmonary morbidity.

METHODS

Patients with AMI and CMI from 2008 to 2019 were identified to determine independent predictors of CV (cardiac arrest, MI, DVT, and stroke) and pulmonary (pneumonia and ventilator time>48 h) morbidities in patients undergoing MB.

RESULTS

377 patients were identified. Patients with AMI had higher rates of preoperative SIRS/sepsis (28 vs 12%, P < .0001), were more likely to be ASA class 4/5 (55 vs 42%, P = .005), were more likely to require bowel resection (19 vs 3%, P < .0001), and were more likely to have vein utilized as their bypass conduit (30 vs 14%, P < .0001). There were no differences in use of aortic or iliac inflow (P = .707) nor in return to the OR (24 vs 19%, P = .282). Both postoperative sepsis (12 vs 2.6%, P = .003) and mortality (31.4% vs 9.8%, P < .0001) were significantly increased in patients with AMI. After adjusting for both patient and procedural factors, multivariable logistic regression (MLR) identified international normalized ratio (INR) (OR 3.16; 95% CI 1.56-6.40, P = .001) and chronic heart failure (CHF) (OR 5.88; 95% CI 1.15-29.97, P = .033) to be independent predictors of pulmonary morbidity, while preoperative sepsis (OR 1.96; 95% CI 1.45-2.66, P < .0001) alone was predictive of CV morbidity in all patients undergoing MB.

DISCUSSION

Mesenteric bypass for mesenteric ischemia leads to high rates of morbidity and mortality, whether done in an acute or chronic setting. Preoperative sepsis, independent of AMI or CMI, predicts CV morbidity, regardless of bypass configuration or conduit, while elevated INR or underlying CHF carries a higher risk of pulmonary morbidity.

It is not all black and white: The effect of increasing severity of frailty on outcomes of geriatric trauma patients

BACKGROUND

Frailty is associated with poor outcomes in trauma patients. However, the spectrum of physiologic deficits, once a patient is identified as frail, is unknown. The aim of this study was to assess the dynamic association between increasing frailty and outcomes among frail geriatric trauma patients.

METHODS

This is a secondary analysis of the American Association of Surgery for Trauma Frailty Multi-institutional Trial. Patients 65 years or older presenting to one of the 17 trauma centers over 3 years (2019-2022) were included. Frailty was assessed within 24 hours of presentation using the Trauma-Specific Frailty Index (TSFI) questionnaire. Patients were stratified by TSFI score into six groups: nonfrail (<0.12), Grade I (0.12-0.19), Grade II (0.20-0.29), Grade III (0.30-0.39), Grade IV (0.40-0.49), and Grade V (0.50-1). Our Outcomes included in-hospital and 3-month postdischarge mortality, major complications, readmissions, and fall recurrence. Multivariable regression analyses were performed.

RESULTS

There were 1,321 patients identified. The mean (SD) age was 77 years (8.6 years) and 49% were males. Median [interquartile range] Injury Severity Score was 9 [5-13] and 69% presented after a low-level fall. Overall, 14% developed major complications and 5% died during the index admission. Among survivors, 1,116 patients had a complete follow-up, 16% were readmitted within 3 months, 6% had a fall recurrence, 7% had a complication, and 2% died within 3 months postdischarge. On multivariable regression, every 0.1 increase in the TSFI score was independently associated with higher odds of index-admission mortality and major complications, and 3 months postdischarge mortality, readmissions, major complications, and fall recurrence.

CONCLUSION

The frailty syndrome goes beyond a binary stratification of patients into nonfrail and frail and should be considered as a spectrum of increasing vulnerability to poor outcomes. Frailty scoring can be used in developing guidelines, patient management, prognostication, and care discussions with patients and their families.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

What Is Going on in Our Schools? Review of Injuries Among School Children Across the United States

INTRODUCTION

Children spend most of their time at school and participate in many activities that have the potential for causing injury. This study aims to describe the nationwide epidemiology of pediatric trauma sustained in school settings in the United States.

METHODS

In the 3-y analysis of 2017-2019 American College of Surgeons-Trauma Quality Program, all pediatric trauma patients (≤18 y) injured in a school setting were included and stratified based on place of injury, into elementary, middle, and high school (HS) groups. Descriptive statistics and multivariable logistic regression analysis were performed to identify the independent predictors of intentional injuries.

RESULTS

23,215 pediatric patients were identified, of which 15,264 patients were injured at elementary (57.6%), middle (17.5%), and high (25%) schools. The mean age was 9.5 y, 66.9% were male, 63.9% were white, the median injury severity score was 2 [1-4], and 95.6% had a blunt injury. Elementary school students were more likely to sustain falls (85%) and humerus fractures (43%) whereas HS students were more likely to be injured by assaults (17%). Overall, 7% of the students sustained intentional injuries. On multivariable logistic regression, male gender (odds ratio [OR] 1.54), Black race (OR 2.94), American Indian race (OR 1.88), Hispanic ethnicity (OR 1.77), positive drug screen (OR 4.9), middle (OR 5.2), and HSs (OR 10.6) were identified as independent predictors of intentional injury (all P < 0.01).

CONCLUSIONS

Injury patterns vary across elementary, middle, and HSs. Racial factors appear to influence intentional injuries along with substance abuse. Further studies to understand these risk factors and efforts to reduce school injuries are warranted to provide a safe learning environment for children.

Timing to Rib Fixation in Patients With Flail Chest

INTRODUCTION

Flail chest (FC) after blunt trauma is associated with significant morbidity and prolonged hospitalizations. The goal of this study was to examine the relationship between timing of rib fixation (ORIF) and pulmonary morbidity and mortality in patients with FC.

METHODS

FC patients were identified from the Trauma Quality Improvement Program database over 3-year, ending 2019. Demographics, severity of injury and shock, time to ORIF, pulmonary morbidity, and mortality were recorded. Youden's index identified optimal time to ORIF. Patients were compared based on undergoing ORIF versus nonoperative management, then for patients undergoing ORIF based on time from admission to operation, utilizing Youden's index to determine the preferred time for fixation. Multivariable logistic regression determined predictors of pulmonary morbidity and mortality.

RESULTS

20,457 patients were identified: 3347 (16.4%) underwent ORIF. The majority were male (73%) with median age and injury severity score of 58 and 22, respectively. Patients undergoing ORIF were clinically similar to those managed nonoperatively but had increased pulmonary morbidity (27.6 versus 15.2%, P < 0.0001) and reduced mortality (2.9 versus 11.7%, P < 0.0001). Multivariable logistic regression identified ORIF as the only modifiable risk factor significantly associated with reduced mortality (odds ratio: 0.26; 95% CI:0.21-0.32, P < 0.0001). Youden's index identified the inflection point for time to ORIF as 4 d postinjury: EARLY (≤4 d) and LATE (>4 d). EARLY fixation was associated with a significant decrease in ventilator days, intensive care unit and hospital length of stay, and pulmonary morbidity.

CONCLUSIONS

Patients undergoing ORIF for FC experienced increased pulmonary morbidity; however, had an associated reduced mortality benefit compared to the nonoperative cohort. EARLY ORIF was associated with a reduction in pulmonary morbidity, without impacting the mortality benefit found with ORIF. Thus, for patients with FC, ORIF performed within 4 d postinjury may help reduce pulmonary morbidity, length of stay, and mortality.

Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis

INTRODUCTION

There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy.

METHODS

We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed.

RESULTS

Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value <0.001), complications (49% versus 37%; P value = 0.01), failure to rescue (66% versus 36%, P value<0.001), and pRBC (units, median, 11 [7-18] versus 7 [4-11], P value <0.001) transfusion requirements. There were no significant differences in hospital and intensive care unit (ICU) lengths of stay (P value ≥0.05). On multivariate analysis, increasing age (adjusted odds ratio [aOR] 1.02, P value <0.001), Glasgow Coma Scale score ≤8 at presentation (aOR 3.3, P value <0.001), and total splenectomy (aOR 5.7, P value <0.001) were associated with higher odds of mortality. Platelet transfusion was associated with lower odds of mortality (aOR 0.84, P value = 0.044).

CONCLUSIONS

On a national scale, mortality following trauma laparotomy is twice as high for cirrhotic patients compared to noncirrhotic patients with higher rates of major complications and failure to rescue. Our finding of a protective effect of platelet transfusion may be explained by the platelet dysfunction associated with cirrhosis. Liver cirrhosis among trauma patients warrants heightened surveillance.

Effect of PCC on outcomes of severe traumatic brain injury patients on preinjury anticoagulation

INTRODUCTION

This study aims to evaluate effect of 4-factor PCC on outcomes of severe TBI patients on preinjury anticoagulants undergoing craniotomy/craniectomy.

METHODS

In this analysis of 2018-2020 ACS-TQIP, patients with isolated blunt severe TBI (Head-AIS≥3, nonhead-AIS<2) using preinjury anticoagulants who underwent craniotomy/craniectomy were identified and stratified into PCC and No-PCC groups. Outcomes were time to surgery and mortality. Multivariable binary logistic and linear regression analyses were performed.

RESULTS

1598 patients were identified (PCC-107[7 %], No-PCC-1491[93 %]). Mean age was 74(11) years, 65 % were male, median head AIS was 4. Median time to PCC administration was 109 ​min. On univariable analysis, PCC group had shorter time to surgery (PCC-341, No-PCC-620 ​min, p ​= ​0.002), but higher mortality (PCC35 %, No-PCC21 %,p ​= ​0.001). On regression analysis, PCC was independently associated with shorter time to surgery (β ​= ​-1934,95 %CI ​= ​-3339to-26), but not mortality (aOR ​= ​0.70,95 %CI ​= ​0.14-3.62).

CONCLUSION

PCC may be a safe adjunct for urgent reversal of coagulopathy in TBI patients using preinjury anticoagulants.

Risk Factors for Acute Renal Failure After Endovascular Aneurysm Repair

BACKGROUND

Acute kidney injury (AKI) after endovascular aortic aneurysm repair (EVAR) is uncommon though carries significant morbidity. Procedural risk factors are not well established for acute renal failure (ARF) that requires initiation of dialysis. The goal of this study was to examine the impact of ARF on patients undergoing EVAR and identify risk factors for ARF using a large, national dataset.

METHODS

Patients undergoing EVAR were identified from the National Surgical Quality Improvement Program (NSQIP) database over 9 years, ending in 2019. Demographics, indication for repair, comorbidities, procedural details, complications, hospital and ICU LOS, and mortality were recorded. Patients were stratified by presence of ARF and compared. Patients were further stratified by indication for EVAR and presence of ARF. Multivariable logistic regression (MLR) analysis was performed to determine the independent predictors of ARF.

RESULTS

18 347 patients were identified. Of these 234 (1.3%) developed ARF requiring dialysis. Mortality (40 vs 1.8%, P < .0001), ICU LOS (5 vs 0 days, P < .0001), and hospital LOS (11 vs 2 days, P < .0001) were all significantly increased in patients with ARF. Multivariable logistic regression identified increasing diameter, creatinine, operative time, preoperative transfusions, ASA class, emergent repair, female gender, and juxtarenal/suprarenal proximal landing zone as predictors of ARF.

CONCLUSIONS

ARF after EVAR causes significant morbidity, prolongs hospitalizations, and increases mortality rates. Those patients at risk of ARF after EVAR should be closely monitored to reduce both morbidity and mortality.

Trauma in the Geriatric and the Super-Geriatric: Should They Be Treated the Same?

INTRODUCTION

There is paucity of studies comparing the characteristics of trauma in geriatrics and super-geriatrics. We aimed to explore the injury characteristics and outcomes of older adult trauma patients on a nationwide scale.

METHODS

This is a retrospective analysis of 2017-2019 American College of Surgeons Trauma Quality Improvement Program. We included moderate to severely injured (Injury Severity Score >8) older adult (≥65 y) trauma patients. Patients were stratified into geriatric (65 y ≤ Age <80 y) and super-geriatric (Age ≥80 y). Outcomes included interventions, complications, failure-to-rescue, withdrawal of support treatment, and mortality.

RESULTS

We identified 269,208 patients (geriatric = 57%; super-geriatric = 43%). Both groups had similar vital signs and Injury Severity Score (geriatric = 9[9-12] versus super-geriatric = 9[9-11]). The super-geriatric were more likely to have falls (71% versus 89%, P < 0.001), while the geriatric were more likely to have Motor vehicle collision (17% versus. 7%, P < 0.001). On multivariate analyses, geriatric patients were more likely to be treated at a Level I Trauma Center (adjusted Odds Ratio [aOR] = 1.1, P < 0.001), undergo hemorrhage control surgery (aOR = 1.5, P < 0.001), be admitted to the intensive care unit (aOR = 1.15, P < 0.001), or intubated (aOR = 1.4, P < 0.001). However, they were less likely to have withdrawal of support treatment (aOR = 0.37, P < 0.001) compared to the super-geriatric. Furthermore, geriatric patients were more likely to develop major complications (aOR = 1.08, P < 0.01). However, they had lower odds of failure-to-rescue (aOR = 0.69, P < 0.001) and in-hospital mortality (aOR = 0.56, P < 0.001) compared to the super-geriatric.

CONCLUSIONS

Significant differences exist in injury patterns, interventions, and outcomes between the geriatric and super-geriatric. Future studies and guidelines may need to classify older adults into geriatric and super-geriatric categories to facilitate tailored care and overall improvement of management strategies for older populations.

Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes?

INTRODUCTION

It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes.

STUDY DESIGN

Patients ≥65 years were identified from the Trauma Quality Improvement Program (TQIP) database (2017-2019). Patients transferred, discharged from emergency department (ED), and those with head abbreviated injury scale >3 were excluded. 11-factor modified frailty index was utilized. Propensity score matching (1:1) was performed. Outcomes included discharge to skilled nursing facility or rehab (SNF/rehab), withdrawal of life-supporting treatment (WLST), mortality, complications, failure-to-rescue, intensive care unit (ICU) admission, hospital length of stay (LOS), and ventilator days.

RESULTS

110,680 patients were matched (Frail:55,340, Non-Frail:55,340). Mean age was 79 (7), 90% presented following falls, and median ISS was 5 [2-9]. Level-I/II TCs had lower rates of discharge to SNF/rehab (52.6% vs. 55.8% vs. 60.9%; p < 0.001), failure-to-rescue (0.5% vs. 0.4% vs. 0.6%;p = 0.005), and higher rates of WLST (2.4% vs. 2.1% vs. 0.3%; p < 0.001) compared to level-III regardless of injury severity and frailty. Compared to Level-III centers, Level-I/II centers had higher complications among moderate-to-severely injured patients (4.1% vs. 3.3% vs. 2.7%; p < 0.001), and lower mortality only among frail patients regardless of injury severity (1.8% vs. 1.5% vs. 2.6%; p < 0.001). Patients at Level-I TCs were more likely to be admitted to ICU, and had longer hospital LOS and ventilator days compared to Level-II and III TCs (p < 0.05).

CONCLUSION

Frailty may play an important role when triaging geriatric trauma patients. In fact, the benefit of care at higher-level TCs is particularly evident for patients who are frail. Level III centers may be underperforming in providing access to palliative and end-of-life care.

Delayed versus early hepatic resection among patients with severe traumatic liver injuries undergoing damage control laparotomy

INTRODUCTION

We aimed to assess the effect of time to hepatic resection on the outcomes of patients with high-grade liver injuries who underwent damage control laparotomy (DCL).

METHODS

This is a 4-year (2017-2020) analysis of the ACS-TQIP. Adult trauma patients with severe liver injuries (AAST-OIS grade ​≥ ​III) who underwent DCL and hepatic resection were included. We excluded patients with early mortality (<24 ​h). Patients were stratified into those who received hepatic resection within the initial operation (Early) and take-back operation (Delayed).

RESULTS

Of 914 patients identified, 29% had a delayed hepatic resection. On multivariable regression analyses, although delayed resection was not associated with mortality (aOR:1.060,95%CI[0.57-1.97],p ​= ​0.854), it was associated with higher complications (aOR:1.842,95%CI[1.38-2.46],p ​< ​0.001), and longer hospital (β: +0.129, 95%CI[0.04-0.22],p ​= ​0.005) and ICU (β:+0.198,95%CI[0.14-0.25],p ​< ​0.001) LOS, compared to the early resection.

CONCLUSION

Delayed hepatic resection was associated with higher adjusted odds of major complications and longer hospital and ICU LOS, however, no difference in mortality, compared to early resection.

Not all traumatic brain injury patients on preinjury anticoagulation are the same

BACKGROUND

Prognostic significance of different anticoagulants in TBI patients remains unanswered. We aimed to compare effects of different anticoagulants on outcomes of TBI patients.

METHODS

A secondary analysis of AAST BIG MIT. Blunt TBI patients ≥50 years using anticoagulants presenting ICH were identified. Outcomes were progression of ICH and need for neurosurgical intervention (NSI).

RESULTS

393 patients were identified. Mean age was 74 and most common anticoagulant was aspirin (30%), followed by Plavix (28%), and coumadin (20%). 20% had progression of ICH and 10% underwent NSI. On multivariate regression for ICH progression, warfarin, SDH, IPH, SAH, alcohol intoxication and neurologic exam deterioration were associated with increased odds. Warfarin, abnormal neurologic exam on presentation, and SDH were independent predictors of NSI.

CONCLUSIONS

Our findings reflect a dynamic interaction between type of anticoagulants, bleeding pattern & outcomes. Future modifications of BIG may need to take the type of anticoagulant into consideration.

Local Antibiotic Therapy for Open Long Bone Fractures: Appropriate Prophylaxis or Unnecessary Exposure for the Orthopedic Trauma Patient?

INTRODUCTION

Prophylactic local antibiotic therapy (LAbT) to prevent infection in open long bone fracture (OLBF) patients has been in use for many decades despite lack of definitive evidence confirming a beneficial effect. We aimed to evaluate the effect of LAbT on outcomes of OLBF patients on a nationwide scale.

MATERIALS AND METHODS

In this retrospective analysis of 2017-2018 American College of Surgeons-Trauma Quality Improvement Program database, all adult (≥18 years) patients with isolated OLBF (non-extremity-Abbreviated Injury Scale < 3) were included. We excluded early deaths (<24 h) and those who had burns or non-extremity surgery. Outcomes were infectious complications (superficial surgical site infection, deep superficial surgical site infection, osteomyelitis, or sepsis), unplanned return to operating room, and hospital and intensive care unit length of stay (LOS). Patients were stratified into two groups: those who received LAbT and those who did not receive LAbT (No-LAbT). Propensity score matching (1:3) and chi-square tests were performed.

RESULTS

A total of 61,337 isolated OLBF patients were identified, among whom 2,304 patients were matched (LAbT: 576; No-LAbT: 1,728). Both groups were similar in terms of baseline characteristics. Mean age was 43 ± 17 years, 75% were male, 14% had penetrating injuries, and the median extremity-Abbreviated Injury Scale was 1 (1-2). Most common fracture locations were tibia (66%), fibula (49%), femur (24%), and ulna (11%). About 52% of patients underwent external fixation, 79% underwent internal fixation, and 86% underwent surgical debridement. The median time to LAbT was 17 (5-72) h, and the median time to debridement was 7 (3-15) h (85% within 24 h). The LAbT group had similar rates of infectious complications (3.5% vs. 2.5%, P = 0.24) and unplanned return to the operating room (2.3% vs. 2.0%, P = 0.74) compared to the No-LAbT group. Patients who received LAbT had longer hospital LOS (16 [10-29] vs. 14 [9-24] days, P < 0.001) but similar intensive care unit LOS (4 [3-9] vs. 4 [2-7] days, P = 0.19).

CONCLUSIONS

Our findings indicate that prophylactic LAbT for OLBF may not be beneficial over well-established standards of care such as early surgical debridement and systemic antibiotics. Prospective studies evaluating the efficacy, risks, costs, and indications of adjuvant LAbT for OLBF are warranted.

There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis

BACKGROUND

Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP).

STUDY DESIGN

Retrospective analysis of the Nationwide Readmissions Database (2017). All frail geriatric (65 years or older) patients with ABP were included. Patients were grouped by treatment at index admission: CCY vs NOM with endoscopic retrograde cholangiopancreatography. Propensity score matching was performed in a 1:2 ratio. Primary outcomes were 6-month readmissions, mortality, and length of stay. Secondary outcomes were 6-month failure of NOM defined as readmission for recurrent ABP, unplanned pancreas-related procedures, or unplanned CCY. Subanalysis was performed to compare outcomes of unplanned CCY vs early CCY.

RESULTS

A total of 29,130 frail geriatric patients with ABP were identified and 7,941 were matched (CCY 5,294; NOM 2,647). Patients in the CCY group had lower 6-month rates of readmission for pancreas-related complications, unplanned readmissions for pancreas-related procedures, overall readmissions, and mortality, as well as fewer hospitalized days (p < 0.05). NOM failed in 12% of patients and 7% of NOM patients were readmitted within 6 months to undergo CCY, of which 56% were unplanned. Patients who underwent unplanned CCY had higher complication rates and hospital costs, longer hospital lengths of stay, and increased mortality compared with early CCY (p < 0.05).

CONCLUSIONS

For frail geriatric patients with ABP, early CCY was associated with lower 6-month rates of complications, readmissions, mortality, and fewer hospitalized days. NOM was unsuccessful in nearly 1 of 7 within 6 months; of these, one-third required unplanned CCY. Early CCY should be prioritized for frail geriatric ABP patients when feasible.

The undisclosed disclosures: The dollar-outcome relationship in resuscitative endovascular balloon occlusion of the aorta

BACKGROUND

Despite its rapid evolution, resuscitative endovascular balloon occlusion of the aorta (REBOA) remains a controversial intervention that continues to generate active research. Proper conflict of interest (COI) disclosure helps to ensure that research is conducted objectively, without bias. We aimed to identify the accuracy of COI disclosures in REBOA research.

METHODS

Literature search was performed using the keyword "REBOA" on PubMed. Studies on REBOA with at least one American author published between 2017 and 2022 were identified. The Centers for Medicare and Medicaid Services Open Payments database was used to extract information regarding payments to the authors from the industry. This was compared with the COI section reported in the manuscripts. Conflict of interest disclosure was defined as inaccurate if the authors failed to disclose any amount of money received from the industry. Descriptive statistics were performed.

RESULTS

We reviewed a total of 524 articles, of which 288 articles met the inclusion criteria. At least one author received payments in 57% (165) of the articles. Overall, 59 authors had a history of payment from the industry. Conflict of interest disclosure was inaccurate in 88% (145) of the articles where the authors received payment.

CONCLUSION

Conflict of interest reports are highly inaccurate in REBOA studies. There needs to be standardization of reporting of conflicts of interest to avoid potential bias.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Emergency Department Shock Index Outperforms Prehospital and Delta Shock Indices in Predicting Outcomes of Trauma Patients

INTRODUCTION

Multiple shock indices (SIs), including prehospital, emergency department (ED), and delta (ED SI - Prehospital SI) have been developed to predict outcomes among trauma patients. This study aims to compare the predictive abilities of these SIs for outcomes of polytrauma patients on a national level.

METHODS

This was a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (2017-2018). We included adult (≥18 y) trauma patients and excluded patients who were transferred, had missing vital signs, and those with severe head injuries (Head-Abbreviated Injury Scale>3). Outcome measures were 24-h and in-hospital mortality, 24-h packed red blood cells transfusions, and intensive care unit and hospital length of stay. Predictive performances of these SIs were evaluated by the Area Under the Receiver Operating Characteristics for the entire study cohort and across all injury severities.

RESULTS

A total of 750,407 patients were identified. Meanstandard deviation age and lowest systolic blood pressure were 53 ± 21 y, and 81 ± 32 mmHg, respectively. Overall, 24-h and in-hospital mortality were 1.2% and 2.5%, respectively. On multivariable analysis, all three SIs were independently associated with higher rates of 24-h and in-hospital mortality, blood product requirements, intensive care unit and hospital length of stay (P < 0.001). ED SI was superior to prehospital and delta SIs (P < 0.001) for all outcomes. On subanalysis of patients with moderate injuries, severe injuries, and positive delta SI, the results remained the same.

CONCLUSIONS

ED SI outperformed both prehospital and delta SIs across all injury severities. Trauma triage guidelines should prioritize ED SI in the risk stratification of trauma patients who may benefit from earlier and more intense trauma activations.

Does preinjury anticoagulation worsen outcomes among traumatic hemothorax patients? A nationwide retrospective analysis

INTRODUCTION

Up to a quarter of all traumatic deaths are due to thoracic injuries. Current guidelines recommend consideration of evacuation of all hemothoraces with tube thoracostomy. The aim of our study was to determine the impact of pre-injury anticoagulation on outcomes of traumatic hemothorax patients.

MATERIALS AND METHODS

We performed a 4-year (2017 - 2020) analysis of the ACS-TQIP database. We included all adult trauma patients (age ≥18 years) presenting with hemothorax and no other severe injuries (other body regions <3). Patients with a history of bleeding disorders, chronic liver disease, or cancer were excluded from this study. Patients were stratified into two groups based on the history of preinjury anticoagulant use (AC, preinjury anticoagulant use: No-AC, no preinjury anticoagulant use). Propensity score matching (1:1) was done by adjusting for demographics, ED vitals, injury parameters, comorbidities, thromboprophylaxis type, and trauma center verification level. Outcome measures were interventions for hemothorax (chest tube, video-assisted thoracoscopic surgery [VATS]), reinterventions (chest tube > once), overall complications, hospital length of stay (LOS), and mortality.

RESULTS

A matched cohort of 6,962 patients (AC, 3,481; No-AC, 3,481) was analyzed. The median age was 75 years, and the median ISS was 10. The AC and No-AC groups were similar in terms of baseline characteristics. Compared to the No-AC group, AC group had higher rates of chest tube placement (46% vs 43%, p = 0.018), overall complications (8% vs 7%, p = 0.046), and longer hospital LOS (7[4-12] vs 6[3-10] days, p ≤ 0.001). Reintervention and mortality rates were similar between the groups (p>0.05).

CONCLUSION

The use of preinjury anticoagulants in hemothorax patients negatively impacts patient outcomes. Increased surveillance is required while dealing with hemothorax patients on pre-injury anticoagulants, and consideration should be given to earlier interventions for such patients.

Interfacility transfer of pediatric trauma patients to higher levels of care: The effect of transfer time and level of receiving trauma center

BACKGROUND

Interfacility transfer of pediatric trauma patients to pediatric trauma centers (PTCs) after evaluation in nontertiary centers is associated with improved outcomes. We aimed to assess the outcomes of transferred pediatric patients based on their severity of the injury, transfer time, and level of receiving PTCs.

METHODS

This is a 3-year (2017-2019) analysis of the American College of Surgeons Trauma Quality Improvement Program database. All children (younger than 15 years) who were transferred from other facilities to Level I or II PTC were included and stratified by level of receiving PTCs and injury severity. Outcome measures were in-hospital mortality and major complications.

RESULTS

A total of 67,726 transferred pediatric trauma patients were identified, of which 52,755 were transferred to Level I and 14,971 to Level II. The mean ± SD age and median Injury Severity Score were 7 ± 4 years and 4 (1-6), respectively. Eighty-five percent were transported by ground ambulance. The median transfer time for Levels I and II was 93 (70-129) and 90 (66-128) minutes, respectively ( p < 0.001). On multivariable regression, interfacility transfers to Level I PTCs were associated with decreased risk-adjusted odds of in-hospital mortality among the mildly to moderately injured group (adjusted odds ratio, 0.59; p = 0.037) and severely injured group with a transfer time of less than 60 minutes (adjusted odds ratio, 0.27; p = 0.002).

CONCLUSION

Every minute increase in the interfacility transfer time is associated with a 2% increase in risk-adjusted odds of mortality among severely injured pediatric trauma patients. Factors other than the level of receiving PTCs, such as estimated transfer time and severity of injury, should be considered while deciding about transferring pediatric trauma patients to higher levels of care.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

The unexpected paradox of geriatric traumatic brain injury outcomes: Uncovering racial and ethnic disparities

BACKGROUND

Healthcare disparities have always challenged surgical care in the US. We aimed to assess the influence of disparities on cerebral monitor placement and outcomes of geriatric TBI patients.

METHODS

Analysis of 2017-2019 ACS-TQIP. Included severe TBI patients ≥65 years. Patients who died within 24 h were excluded. Outcomes included mortality, cerebral monitors use, complications, and discharge disposition.

RESULTS

We included 208,495 patients (White = 175,941; Black = 12,194) (Hispanic = 195,769; Non-Hispanic = 12,258). On multivariable regression, White race was associated with higher mortality (aOR = 1.26; p < 0.001) and SNF/rehab discharge (aOR = 1.11; p < 0.001) and less likely to be discharged home (aOR = 0.90; p < 0.001) or to undergo cerebral monitoring (aOR = 0.77; p < 0.001) compared to Black. Non-Hispanics had higher mortality (aOR = 1.15; p = 0.013), complications (aOR = 1.26; p < 0.001), and SNF/Rehab discharge (aOR = 1.43; p < 0.001) and less likely to be discharged home (aOR = 0.69; p < 0.001) or to undergo cerebral monitoring (aOR = 0.84; p = 0.018) compared to Hispanics. Uninsured Hispanics had the lowest odds of SNF/rehab discharge (aOR = 0.18; p < 0.001).

CONCLUSIONS

This study highlights the significant racial and ethnic disparities in the outcomes of geriatric TBI patients. Further studies are needed to address the reason behind these disparities and identify potentially modifiable risk factors in the geriatric trauma population.

Unequal Treatment? Confronting Racial, Ethnic, and Socioeconomic Disparity in Management of Survivors of Violent Suicide Attempt

BACKGROUND

Psychiatric inpatient hospitalization is nearly always indicated for patients with recent suicidal behavior. We aimed to assess the factors associated with receiving mental health services during hospitalization or on discharge among survivors of suicide attempts in trauma centers.

STUDY DESIGN

A 3-year analysis of the 2017 to 2019 American College of Surgeons TQIP. Adults (≥18 years) presenting after suicide attempts were included. Patients who died, those with emergency department discharge disposition, those with superficial lacerations, and those who were transferred to nonpsychiatric care facilities were excluded. Backward stepwise regression analyses were performed to identify predictors of receiving mental health services (inpatient psychiatric consultation/psychotherapy, discharge/transfer to a psychiatric hospital, or admission to a distinct psychiatric unit of a hospital).

RESULTS

We identified 18,701 patients, and 56% received mental health services. The mean age was 40 ± 15 years, 72% were males, 73% were White, 57% had a preinjury psychiatric comorbidity, and 18% were uninsured. Of these 18,701 patients, 43% had moderate to severe injuries (Injury Severity Score > 8), and the most common injury was cut/stab (62%), followed by blunt mechanisms (falls, lying in front of a moving object, and intentional motor vehicle collisions) (18%) and firearm injuries (16%). On regression analyses, Black race, Hispanic ethnicity, male sex, younger age, and positive admission alcohol screen were associated with lower odds of receiving mental health services (p < 0.05). Increasing injury severity, being insured, having preinjury psychiatric diagnosis, and positive admission illicit drug screen were associated with higher odds of receiving mental health services (p < 0.05).

CONCLUSIONS

Significant disparities exist in the management of survivors of suicide attempts. There is a desperate need for improved access to mental health services. Further studies should focus on delineating the cause of these disparities, identifying the barriers, and finding solutions.

Time to Whole Blood Transfusion in Hemorrhaging Civilian Trauma Patients: There Is Always Room for Improvement

BACKGROUND

Whole blood (WB) is becoming the preferred product for the resuscitation of hemorrhaging trauma patients. However, there is a lack of data on the optimum timing of receiving WB. We aimed to assess the effect of time to WB transfusion on the outcomes of trauma patients.

STUDY DESIGN

The American College of Surgeons TQIP 2017 to 2019 database was analyzed. Adult trauma patients who received at least 1 unit of WB within the first 2 hours of admission were included. Patients were stratified by time to first unit of WB transfusion (first 30 minutes, second 30 minutes, and second hour). Primary outcomes were 24-hour and in-hospital mortality, adjusting for potential confounders.

RESULTS

A total of 1,952 patients were identified. Mean age and systolic blood pressure were 42 ± 18 years and 101 ± 35 mmHg, respectively. Median Injury Severity Score was 17 [10 to 26], and all groups had comparable injury severities (p = 0.27). Overall, 24-hour and in-hospital mortality rates were 14% and 19%, respectively. Transfusion of WB after 30 minutes was progressively associated with increased adjusted odds of 24-hour mortality (second 30 minutes: adjusted odds ratio [aOR] 2.07, p = 0.015; second hour: aOR 2.39, p = 0.010) and in-hospital mortality (second 30 minutes: aOR 1.79, p = 0.025; second hour: aOR 1.98, p = 0.018). On subanalysis of patients with an admission shock index >1, every 30-minute delay in WB transfusion was associated with higher odds of 24-hour (aOR 1.23, p = 0.019) and in-hospital (aOR 1.18, p = 0.033) mortality.

CONCLUSIONS

Every minute delay in WB transfusion is associated with a 2% increase in odds of 24-hour and in-hospital mortality among hemorrhaging trauma patients. WB should be readily available and easily accessible in the trauma bay for the early resuscitation of hemorrhaging patients.

Dealing with the elder abuse epidemic: Disparities in interventions against elder abuse in trauma centers

BACKGROUND

Elder abuse is a major cause of injury, morbidity, and death. We aimed to identify the factors associated with interventions against suspected physical abuse in older adults.

METHODS

Analysis of the 2017-2018 ACS TQIP. All trauma patients ≥60 years with an abuse report for suspected physical abuse were included. Patients with missing information on abuse interventions were excluded. Outcomes were rates of abuse investigation initiation following an abuse report and change of caregiver at discharge among survivors with an abuse investigation initiated. Multivariable regression analyses were performed.

RESULTS

Of 727,975 patients, 1405 (0.2%) had an abuse report. Patients with an abuse report were younger (mean, 72 vs 75, p < 0.001), and more likely to be females (57% vs 53%, p = 0.007), Hispanic (11% vs 6%, p < 0.001), Black (15% vs 7%, p < 0.001), suffer from dementia (18% vs 11%, p < 0.001), functional disability (19% vs 15%, p < 0.001), have a positive admission drug screen (9% vs 5%, p < 0.001) and had a higher ISS (median [IQR], 9 [4-16] vs 6 [3-10], p < 0.001). Perpetrators were members of the immediate/step/extended family in 91% of cases. Among patients with an abuse report, 1060 (75%) had abuse investigations initiated. Of these, 227 (23%) resulted in a change of caregiver at discharge. On multivariate analysis for abuse investigation initiation, male gender, private insurance, and management at non-level I trauma centers were associated with lower adjusted odds (p < 0.05), while Hispanic ethnicity, positive admission drug screen, and penetrating injury were associated with higher adjusted odds (p < 0.05). On multivariate analysis for change of caregiver, male gender, and private insurance were associated with lower adjusted odds (p < 0.05), while functional disability and dementia were associated with higher adjusted odds (p < 0.05).

CONCLUSIONS

Significant gender, ethnic, and socioeconomic disparities exist in the management of physical abuse of older adults. Further studies are warranted to expand on and address the contributing factors underlying these disparities.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Therapeutic/Care Management.

The final decision among the injured elderly, to stop or to continue? Predictors of withdrawal of life supporting treatment

BACKGROUND

There is a paucity of data on factors that influence the decision regarding withdrawal of life supporting treatment (WLST) in geriatric trauma patients. We aimed to identify predictors of WLST in geriatric trauma patients.

METHODS

This retrospective analysis of the American College of Surgeons- Trauma Quality Improvement Program (2017-2019) included all severely injured (Injury Severity Score >15) geriatric trauma patients (≥65 years). Multivariable logistic regression was performed to identify independent predictors of WLST.

RESULTS

There were 155,583 patients included. Mean age was 77 ± 7 years, 55% were male, 97% sustained blunt injury, and the median Injury Severity Score was 17 [16-25]. Overall WLST rate was 10.8%. On MLR analysis, increasing age (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.33-1.37; p < 0.001), male sex (aOR, 1.14; 95% CI, 1.09-1.18; p < 0.001), White race (aOR, 1.44; 95% CI, 1.36-1.52; p < 0.001), frailty (aOR, 1.42; 95% CI, 1.34-1.50; p < 0.001), government insurance (aOR, 1.27; 95% CI, 1.20-1.33; p < 0.001), presence of advance directive limiting care (aOR, 2.55; 95% CI, 2.40-2.70; p < 0.001), severe traumatic brain injury (aOR, 1.80; 95% CI, 1.66-1.95; p < 0.001), ventilator requirement (aOR, 12.73; 95% CI, 12.09-13.39; p < 0.001), and treatment at higher level trauma centers (Level I aOR, 1.49; 95% CI, 1.42-1.57; p < 0.001; Level II aOR, 1.43; 95% CI, 1.35-1.51; p < 0.001) were independently associated with higher odds of WLST.

CONCLUSION

Our results suggest that nearly one in 10 severely injured geriatric trauma patients undergo WLST. Multiple patient and hospital related factors contribute to decision making and directed efforts are necessary to create a more standardized process.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Role of Endovascular Stenting in Patients with Traumatic Iliac Artery Injury

BACKGROUND

Common and external iliac artery injuries (IAI) portend significant morbidity and mortality. The goal of this study was to examine the impact of mechanism of injury and type of repair on outcomes and identify the optimal repair for patients with traumatic IAI using a large, national dataset.

STUDY DESIGN

Patients undergoing operative repair for IAI were identified from the Trauma Quality Improvement Program database during a 5-year timespan, ending in 2019. Age, sex, race, severity of injury, severity of shock, type of iliac repair (open or endovascular), mechanism, morbidity and mortality were recorded. Patients with IAI were stratified by both type of repair and mechanism and compared. Multivariable logistic regression analysis was used to identify independent predictors of mortality.

RESULTS

Operative IAI was identified in 507 patients. Of these injuries, 309 (61%) were penetrating and 346 (68.2%) involved the external iliac artery. The majority of patients were male (82%) with a median age and ISS of 31 and 20, respectively. Endovascular repair was performed in 31% of cases. For patients with penetrating injuries, the type of repair impacted neither morbidity nor mortality. For blunt-injured patients, endovascular repair was associated with lower morbidity (29.3% vs 41.3%; p = 0.082) and significantly reduced mortality (14.6% vs 26.7%; p = 0.037) compared with the open-repair approach. Multivariable logistic regression identified endovascular repair as the only modifiable risk factor associated with decreased mortality (odds ratio 0.34; 95% CI 0.15 to 0.79; p = 0.0116).

CONCLUSIONS

Traumatic IAI causes significant morbidity and mortality. Endovascular repair was identified as the only modifiable predictor of decreased mortality in blunt-injured patients with traumatic IAI. Therefore, for select patients with blunt IAIs, an endovascular repair should be the preferred approach.

Missed blunt cerebrovascular injuries using current screening criteria - The time for liberalized screening is now

Diagnostic Criteria Study BACKGROUND: The morbidity and mortality associated with ischemic stroke attributable to blunt cerebrovascular injury (BCVI) warrant aggressive screening. The Denver Criteria (DC) and Expanded Denver Criteria (eDC) have imprecise elements that can be difficult and subjective in application and can delay or prevent screening. We hypothesize these screening criteria lack adequate ability to consistently identify BCVI and that the use of a liberalized screening approach with CT angiography (CTA) is superior without increasing risk of acute kidney injury (AKI).

METHODS

This was a multi-institutional retrospective cohort study of trauma patients who presented between 2015-2020 with radiographically confirmed BCVI diagnosed using each institutions' liberalized screening protocol, defined as automatic CTA of the head and neck for all patients undergoing head and neck CT. Outcomes of interest included AKI, stroke, and death due to BCVI. Outcomes were reported as frequency, percent, and 95% confidence interval as calculated by the Clopper-Pearson method. Incidence of medical follow-up within 1 year of first medical visit was quantified as the median and inter-quartile range of days to follow-up visit.

RESULTS

We identified 433 BCVI patients with a mean age of 45.2 (standard deviation 18.9) years, 256 men and 177 women, 1.73 m (0.10) tall, and weighed 80.3 kg (20.3). Forty-one patients had strokes (9.5% [95% confidence interval 6.9, 12.6] and 12 patients (2.8% [1.4, 4.5]) had mortality attributable to BCVI. Of 433 total cases, 132 (30.5% [26.2, 35.1]) would have been missed by DC and 150 (34.6% [30.2, 39.3]) by eDC. Incidence of AKI in our BCVI population was 6 (1.4% [0.01, 3.0]).

CONCLUSIONS

BCVI would be missed over 30% of the time using the DC and eDC compared to liberalized use of screening CTA. Risk of AKI due to CTA did not occur at a clinically meaningful level, supporting liberal CTA screening.

The man, the myth, the method: an inside look at the open abdomen and abdominal wall reconstruction

Management of the open abdomen (or the abdomen that will not close) and subsequent abdominal wall reconstruction remains one of the most vexing situations for even the most experienced trauma surgeon. The contribution to the literature on this topic by Dr Timothy Fabian and the Memphis group at the Elvis Presley Trauma Center resulted in the contemporary recognition that the initial management as well as the long-term approach dictates optimal outcomes for patients with this problem. Over three decades, the Memphis group, under Dr Fabian's leadership, performed numerous clinical studies that led to the publication of multiple articles (including a step-by-step how-to manual) for managing the open abdomen from onset to closure. The purpose of this review is to survey the consecutive studies from Memphis specifically that led to the development of a simplified management scheme that has stood the test of time.

Optimal time to thoracoscopy for trauma patients with retained hemothorax

BACKGROUND

Retained hemothorax remains a common problem after thoracic trauma with associated morbidity and prolonged hospitalizations. The goal of this study was to examine the impact of time to video assisted thoracoscopic surgery (VATS) on pulmonary morbidity using a large, national data set.

METHODS

Patients undergoing VATS for retained hemothorax within the first 14 days postinjury were identified from the Trauma Quality Improvement Program database over 5 years, ending in 2016. Demographics, mechanism, severity of injury, severity of shock, time to VATS, pulmonary morbidity, and mortality were recorded. Multivariable logistic regression analysis was performed to determine independent predictors of pulmonary morbidity. Youden's index was then used to identify the optimal time to VATS.

RESULTS

From the Trauma Quality Improvement Program database, 3,546 patients were identified. Of these, 2,355 (66%) suffered blunt injury. The majority were male (81%) with a median age and Injury Severity Score of 46 and 16, respectively. The median time to VATS was 134 hours. Both pulmonary morbidity (13 vs 17%, P = .004) and hospital length of stay (9 vs 12 days, P < .0001) were significantly reduced in patients undergoing VATS before 3.9 days. Multivariable logistic regression identified VATS during the first 7 days as the only modifiable risk factor significantly associated with reduced pulmonary morbidity (odds ratio 0.52; 95% confidence interval 0.43-0.63, P < .0001).

CONCLUSION

Patients undergoing VATS for retained hemothorax have significant morbidity and prolonged length of stay. VATS within the first week of admission results in fewer pulmonary complications and shorter length of stay. In fact, the optimal time to VATS was identified as 3.9 days and was the only modifiable risk factor associated with decreased pulmonary morbidity.

Radiographic and Clinical Predictors of Therapeutic Pelvic Angiography

BACKGROUND

Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT) imaging plays an integral diagnostic role. The purpose of this study was to identify radiographic and clinical predictors of therapeutic angiography in patients with blunt pelvic fractures.

METHODS

All patients with blunt pelvic fractures who underwent angiography following admission CT scan were identified over a 6-year period. A radiologist reviewed the CT scans to identify potential predictors of pelvic hemorrhage. Patients were stratified by intervention [therapeutic angiography (TA) vs non-therapeutic angiography (NTA)] and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of TA. Youden's index was used to identify the optimal value of selected predictors identified on MLR.

RESULTS

177 patients were identified: 42% underwent TA and 58% underwent NTA. Patients undergoing TA were more likely to have a higher injury burden and greater resuscitative transfusion requirements, display both a brighter blush density on arterial phase CT and a larger % change in arterial to venous phase blush density. The optimal arterial blush density was determined to be 250 HU. MLR identified pre-angiography transfusion requirements (OR 1.175; 95% CI 1.054-1.311, P = .0189) and arterial blush density (OR 1.011; 95% CI 1.005-1.016, P < .0001) as independent predictors of therapeutic angiography.

CONCLUSION

CT imaging remains vital in assessing patients with pelvic fractures and associated hemorrhage following blunt trauma. For patients requiring multiple resuscitative transfusions with CT findings of an arterial blush measuring ≥250 HU, early angiography should be the preferred approach.

Re-Sighting the Gun Debate: Defining Patterns of Firearm-Related Death to Help Focus Prevention Efforts

BACKGROUND

Gun violence remains a significant public health problem. Although gun violence prevention efforts mostly target homicides, nationally, two-thirds of all firearm deaths are suicides. The purpose of this study was to define patterns of firearm-related deaths and examine the effect of population size.

STUDY DESIGN

All firearm-related deaths in the US between 1999 and 2016 were analyzed. Homicides and suicides were obtained from the Federal Bureau of Investigation and the Centers for Disease Control and Prevention, respectively, comprising the database. For each state, the largest metropolitan city by population and a corresponding small urban city were selected. Firearm-related deaths were stratified by type and city size and compared. Rates of firearm-related homicides and suicides per 1 million population were stratified by year and compared over time using simple linear regression.

RESULTS

544,749 firearm-related deaths occurred across the US over the study period (38% homicides, 62% suicides). The median rate of firearm-related suicides was significantly greater than firearm-related homicides regardless of city size and across the US. Linear regression analysis failed to identify a significant change in the rate of firearm-related homicides over the study period. However, the rate of firearm-related suicides increased significantly regardless of city size between 1999 and 2016.

CONCLUSION

Although homicides account for the majority of firearm-related deaths in metropolitan areas, suicides constitute a disproportionate number in smaller urban areas. Although the rate of homicides has stabilized, the rate of firearm-related suicides continues to increase significantly, underscoring the need for better direct prevention efforts and public health policy.

Characterization of platelet concentrations and evaluation of risk factors for thrombocytopenia following traumatic injury

Introduction

Thrombocytopenia is common in critically ill trauma patients and can lead to potentially broad differentials, including major bleeding, hemodilution, extracorporeal circuit losses, heparin-induced thrombocytopenia, and more. Understanding the normal time course of platelet decline and recovery may delineate thrombocytopenia(HIT) secondary to traumatic injury versus other inciting factors.

Methods

This retrospective study included trauma patients admitted over a 1-year period. The primary aim was characterizing the effect of trauma on platelet concentration and thrombocytopenia incidence in the first 30 days following injury. Thrombocytopenia was defined as platelet concentration <150 × 109/L. A secondary aim was evaluating significant factors contributing to thrombocytopenia.

Results

A total of 225 patients were included. Thrombocytopenia occurred in 67.3% of patients, and a platelet decline of 50% or greater occurred in 44%. Decrease in platelet concentration was significant from day 1 to day 4 (mean ± SD, 232 ± 86 vs 142 ± 76 × 109/L; p = .001). Platelets recovered to baseline on day 8 and peaked on day 16. Packed red blood cell or platelet transfusion, continuous renal replacement therapy, and acute liver injury independently predicted a ≥50% platelet decrease. HIT was not diagnosed in any patients.

Conclusion

Platelet nadir likely occurs approximately 4 days after injury and recovers relatively quickly thereafter. More studies are needed to evaluate the magnitude of effect on thrombocytopenia by factors beyond trauma.

Serial CT for Nonoperatively Managed Splenic Injuries

INTRODUCTION

The role of serial computed tomography (CT) in the nonoperative management of blunt splenic injuries (NOMSIs) remains unclear. The purpose of the study was to determine the utility of serial CT of Grade 2-5 NOMSI in the modern era.

METHODS

Blunt splenic injuries were identified over a 3.5-year period, ending in 6/2020. Our institutional protocol for NOMSI mandates a repeat 24-hour CT for Grade 2-5 injuries. Patients age<18, Grade 1 injuries and patients that underwent intervention prior to repeat scan were excluded. Demographics, comorbidities, timing of events (admission, CTs, splenectomy, and angiography), injury details, procedural details, total transfusion requirements, complications, length of stay, mortality, and discharge disposition were recorded. Descriptive statistics were performed.

RESULTS

219 patients with Grade 2-5 NOMSI had both an initial and 24-hour CT after exclusions. 24-hour CT identified 14 patients with new PSA(s) and 11 (5%) went to angiography within 24 hours with 9 (4%) undergoing angioembolization and 4 (2%) had splenectomy. Two hundred and four (93%) had no intervention though eventually 12 went on to angiography and 6 went for splenectomy. The 24-hour CT rarely altered management in the absence of clinical indication or prior PSA on initial CT with 5 (2%) receiving a therapeutic embolization and 2 (1%) had a nontherapeutic angiogram. No deaths were attributable to splenic injury.

CONCLUSIONS

Routine 24-hour CT for NOMSI did not impact management. Clinical status and change in exam may warrant repeat CT in select cases in the setting of a plausible alternate explanation. Prompt angioembolization or splenectomy is more appropriate in clear-cut cases of failed NOMSI.

Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes

BACKGROUND

Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury.

METHODS

Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST).

RESULTS

One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017).

CONCLUSION

Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach.

LEVEL OF EVIDENCE

Prognostic study, Level IV.

Caught in the crossfire: 37 Years of firearm violence afflicting America's youth

INTRODUCTION

Publicly available firearm data are difficult to access. Trauma registry data are excellent at documenting patterns of firearm-related injury. Law enforcement data excel at capturing national violence trends to include both circumstances and firearm involvement. The goal of this study was to use publicly available law enforcement data from all 50 states to better define patterns of firearm-related homicides in the young.

METHODS

All homicides in individuals 25 years or younger in the United States over a 37-year period ending in 2016 were analyzed: infant, 1 year or younger; child, 1 to 9 years old; adolescent, 10 to 19 years old; and young adult, 20 to 25 years old. Primary data files were obtained from the Federal Bureau of Investigation and comprised the database. Data analyzed included homicide type, situation, circumstance, month, firearm type, and demographics. Rates of all homicides and firearm-related homicides per 1 million population and the proportion of firearm-related homicides (out of all homicides) were stratified by year and compared over time using simple linear regression.

RESULTS

A total of 171,113 incidents of firearm-related homicide were analyzed (69% of 246,437 total homicides): 5,313 infants, 2,332 children, 59,777 adolescents, and 103,691 young adults. Most (88%) were male and Black (59%) with a median age of 20 years. Firearm-related homicides peaked during the summer months of June, July, and August (median, 1,156 per year; p = 0.0032). Rates of all homicides (89 to 53 per 1 million population) and firearm-related homicides (56 to 41 per 1 million population) decreased significantly from 1980 to 2016 (β = -1.12, p < 0.0001 and β = -0.57, p = 0.0039, respectively). However, linear regression analysis identified a significant increase in the proportion of firearm-related homicides (out of all homicides) from 63% in 1980 to 76% in 2016 (β = 0.33, p < 0.0001).

CONCLUSION

For those 25 years or younger, the proportion of firearm-related homicides has steadily and significantly increased over the past 37 years, with 3 of 4 homicides firearm related in the modern era. Despite focused efforts, reductions in the rate of firearm-related homicides still lag behind those for all other methods of homicide by nearly 50%. That is, while the young are less likely to die from homicide, for those unfortunate victims, it is more likely to be due to a firearm. This increasing role of firearms in youth homicides underscores the desperate need to better direct prevention efforts and firearm policy if we hope to further reduce firearm-related deaths in the young.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Impact of Chemoprophylaxis on Thromboembolism Following Operative Fixation of Pelvic Fractures

BACKGROUND

Venous thromboembolism (VTE) is a common cause of serious morbidity and mortality. While chemoprophylaxis decreases VTE, there is the theoretical risk of increased hemorrhagic complications. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt pelvic fractures requiring operative fixation.

METHODS

Patients with blunt pelvic fractures requiring operative fixation over 10.5 years were identified. Patients were stratified by age, severity of shock, operative management, and timing and duration of anticoagulation. Outcomes were evaluated to determine risk factors for bleeding complications and VTE.

RESULTS

310 patients were identified: 212 patients received at least one dose of preoperative anticoagulation and 98 received no preoperative anticoagulation. 68% were male with a mean injury severity score and Glasgow Coma Scale of 26 and 13, respectively. Bleeding complications occurred in 24 patients and 21 patients suffered VTE. Patients with VTE had a greater initial severity of shock (resuscitation transfusions, 4 vs. 2 units, P = .02). Despite longer time to mobilization (4 vs. 3 days, P = .001), patients who received their scheduled preoperative doses within 48 hours of arrival had no significant differences in the number of deep vein thrombosis events (5.2% vs. 5.7%, P = .99), but fewer episodes of pulmonary embolism (PE) (1.5% vs. 6.8%, P = .03) with no difference in bleeding complications (7.5% vs. 8%, P = .87) compared to either patients who had their doses held until after 48 hours of arrival or received no preoperative anticoagulation.

DISCUSSION

Preoperative anticoagulation prior to pelvic fixation reduced the risk of PE without increasing bleeding complications. Preoperative anticoagulation is safe and beneficial in this group of patients.

Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury

BACKGROUND

Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset.

STUDY DESIGN

Patients with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 10 years, ending in 2016. Patients with BAI were stratified by the presence of concomitant TBI and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in BAI patients with and without TBI. Youden's index was used to identify the optimal time to TEVAR in these patients.

RESULTS

17,040 patients with BAI were identified, with 4,748 (28%) having a TBI. Patients with BAI and TBI were predominantly male, with a higher injury burden and greater severity of shock at presentation, underwent fewer TEVAR procedures, and had increased mortality compared with BAI patients without TBI. The optimal time for TEVAR was 9 hours. Mortality was significantly increased in patients undergoing TEVAR before 9 hours (12.9% vs 6.5%, p = 0.003). For BAI patients with and without TBI, MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (odds ratio [OR] 0.41; 95%CI 0.32-0.54, p < 0.0001).

CONCLUSIONS

TBI significantly increases mortality in BAI patients. TEVAR and delayed repair both significantly reduced mortality. So, for patients with both BAI and TBI, an endovascular repair performed in a delayed fashion should be the preferred approach.

Is NBATS-2 up to the Task? Actual vs. Predicted Patient Volume Shifts With the Addition of Another Trauma Center

INTRODUCTION

Version 2 of the Needs-Based Assessment of Trauma Systems (NBATS) tool quantifies the impact of an additional trauma center on a region. This study applies NBATS-2 to a system where an additional trauma center was added to compare the tool's predictions to actual patient volumes.

METHODS

Injury data were collected from the trauma registry of the initial (legacy) center and analyzed geographically using ArcGIS. From 2012 to 2014 ("pre-"period), one Level 1 trauma center existed. From 2016 to 2018 ("post-"period), an additional Level 2 center existed. Emergency medical service (EMS) destination guidelines did not change and favored the legacy center for severely injured patients (Injury Severity Score (ISS) >15). NBATS-2 predicted volume was compared to the actual volume received at the legacy center in the post-period.

RESULTS

4068 patients were identified across 14 counties. In the pre-period, 72% of the population and 90% of injuries were within a 45-minute drive of the legacy trauma center. In the post-period, 75% of the total population and 90% of injuries were within 45 minutes of either trauma center. The post-predicted volume of severely injured patients at the legacy center was 434, but the actual number was 809. For minor injuries (ISS £15), NBATS-2 predicted 581 vs. 1677 actual.

CONCLUSION

NBATS-2 failed to predict the post-period volume changes. Without a change in EMS destination guidelines, this finding was not surprising for severely injured patients. However, the 288% increase in volume of minor injuries was unexpected. NBATS-2 must be refined to assess the impact of local factors on patient volume.

They only come out at night: Impact of time of day on outcomes after penetrating abdominal trauma

Background

Patients who present at night following penetrating abdominal trauma are thought to have more severe injuries and increased risk for morbidity and mortality. The current literature is at odds regarding this belief. The purpose of this study was to evaluate time of day on outcomes following laparotomy for penetrating abdominal trauma.

Methods

Patients undergoing laparotomy following penetrating abdominal trauma over a 12-month period at a level I trauma center were stratified by age, sex, severity of shock, injury, operative complexity, and time of day (DAY = 0700-1900, NIGHT = 1901-0659). Outcomes of damage control laparotomy, ventilator days, intensive care unit length of stay, hospital length of stay, morbidity, and mortality were compared between DAY and NIGHT.

Results

A total of 210 patients were identified: 145 (69%) comprised NIGHT, and 65 (31%) comprised DAY. Overall mortality was 2.9%. Both injury severity and intraoperative transfusions were increased with NIGHT with no difference in morbidity (37% vs 40%, P = 0.63) or mortality (2.1% vs 4.6%, P = 0.31). Adjusting for sex, time of day, injury severity, and operative complexity, only abdominal abbreviated injury severity (odds ratio 1.46; 95% confidence interval 1.07-1.99, P = .019) and operative transfusions (odds ratio 1.18; 95% confidence interval 1.09-1.28, P < .0001) were identified as independent predictors of damage control laparotomy using multivariable logistic regression (area under the curve 0.96).

Conclusion

The majority of operative penetrating abdominal trauma occurs at night with increased injury burden, more operative transfusions, and increased use of damage control laparotomy with no difference in morbidity and mortality. Outcomes at a fully staffed and operational trauma center should not be impacted by time of day.

How to Increase the Burden on Trauma Centers: Implement the 80-hour Work Week

The 80-hour week was implemented in 2003 to improve outcomes and limit errors. We hypothesize that there has been no change in outcomes postimplementation of the restrictions. Outcomes were queried from the trauma registry from 1997 to 2002 (PRE) and 2004 to 2009 (POST). Primary outcomes were mortality, intensive care unit length of stay (ICU LOS), and length of stay (LOS). Patients were stratified based on demographics, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Score, base deficit). Outcomes were then compared PRE with POST. A total of 41,770 patients were admitted during the study period. The mean age was 38 years with most being male (73%) and blunt mechanism (78%). Although patients admitted in the POST period had a slightly higher blood pressure, they were older and had higher injury severity. ICU LOS, LOS, self-pay, and mortality were higher in the POST period. After adjusted analysis, admission in the POST period was no longer a predictor of mortality (odds ratio, 1.02; confidence interval, 0.92 to 1.14). Whereas patients were more slightly more injured in the POST period, the adjusted analysis shows no difference in mortality and both a longer LOS and ICU LOS. Whether the increase is the result of more severe injury in the POST period or less efficient disposition remains to be elucidated. This study adds to the mounting evidence that the implementation of the limits on work hours does not lead to better outcomes.

Tigecycline to treat Stenotrophomonas maltophilia ventilator-associated pneumonia in a trauma intensive care unit as a result of a drug shortage: A case series

WHAT IS KNOWN AND OBJECTIVE

Stenotrophomonas maltophilia is an intrinsically multidrug-resistant (MDR) organism which commonly presents as a respiratory tract infection. S. maltophilia is typically treated with high-dose sulfamethoxazole/trimethoprim (SMX/TMP). However, SMX/TMP and other treatment options for S. maltophilia can be limited because of resistance, allergy, adverse events or unavailability of the drug; use of novel agents may be necessary to adequately treat this MDR infection and overcome these limitations.

CASE DESCRIPTION

This small case series describes two patients who underwent treatment with tigecycline for ventilator-associated pneumonia (VAP) caused by S. maltophilia after admission to a trauma intensive care unit. At the time of admission for the two reported patients, a national drug shortage of intravenous (IV) SMX/TMP prevented its use. Tigecycline was chosen as a novel agent to treat S. maltophilia VAP based on culture and susceptibility data, and it was used successfully. Both patients showed clinical signs of improvement with eventual cure and discharge from the hospital after treatment with tigecycline, and one patient demonstrated confirmed microbiological cure with a negative repeat bronchoscopic bronchoalveolar lavage (BAL).

WHAT IS NEW AND CONCLUSION

To our knowledge, this small case series is the first documentation of utilizing tigecycline to treat S. maltophilia VAP in the United States. Although it likely should not be considered as a first-line agent, tigecycline proved to be an effective treatment option in the two cases described in the setting of a national drug shortage of the drug of choice.

Radiographic predictors of therapeutic operative intervention after blunt abdominal trauma: the RAPTOR score

PURPOSE

Bowel and mesenteric injuries are rare in patients following blunt abdominal trauma. Computed tomography (CT) imaging has become a mainstay in the work-up of the stable trauma patient. The purpose of this study was to identify radiographic predictors of therapeutic operative intervention for mesenteric and/or bowel injuries in patients after blunt abdominal trauma.

METHODS

All patients with a discharge diagnosis of bowel and/or mesenteric injury after blunt trauma were identified over a 5-year period. Admission CT scans were reviewed to identify potential predictors of bowel and/or mesenteric injury. Patients were then stratified by operative intervention [therapeutic laparotomy (TL) vs. non-therapeutic laparotomy (NTL)] and compared. All potential predictors included in the initial regression model were assigned one point and a score based on the number of predictors was calculated: the radiographic predictors of therapeutic operative intervention (RAPTOR) score.

RESULTS

151 patients were identified. 114 (76%) patients underwent operative intervention. Of these, 75 patients (66%) underwent TL. Multifocal hematoma, acute arterial extravasation, bowel wall hematoma, bowel devascularization, fecalization, pneumoperitoneum and fat pad injury, identified as potential predictors on univariable analysis, were included in the initial regression model and comprised the RAPTOR score. The optimal RAPTOR score was identified as ≥ 3, with a sensitivity, specificity and positive predictive value of 67%, 85% and 86%, respectively. Acute arterial extravasation (OR 3.8; 95% CI 1.2-4.3), bowel devascularization (OR 14.5; 95% CI 11.8-18.4) and fat pad injury (OR 4.5 95% CI 1.6-6.2) were identified as independent predictors of TL (AUC 0.91).

CONCLUSIONS

CT imaging remains vital in assessing for potential bowel and/or mesenteric injuries following blunt abdominal trauma. The RAPTOR score provides a simplified approach to predict the need for early therapeutic operative intervention.

The impact of race and socioeconomic status on the presentation, management and outcomes for gastric cancer patients: Analysis from a metropolitan area in the southeast United States

BACKGROUND

Socioeconomic disparities in gastric cancer have been associated with differences in care and inferior outcomes. We evaluated the presentation, treatment, and survival for patients with gastric cancer (GC) in a metropolitan setting with a large African American population.

METHODS

Retrospective cohort analysis of patients with GC (2003-2018) across a multi-hospital system was performed. Associations between socioeconomic and clinicopathologic data with the presentation, treatment, and survival were examined.

RESULTS

Of 359 patients, 255 (71%) were African American and 104 (29%) Caucasian. African Americans were more likely to present at a younger age (64.0 vs 72.5, P < .001), have state-sponsored or no insurance (19.7% vs 6.9%, P = .02), reside within the lowest 2 quintiles for median income (67.4% vs 32.7%, P < .001), and have higher rates of Helicobacter pylori (14.9% vs 4.8%, P = .02). Receipt of multi-modality therapy was not impacted by race or insurance status. On multivariable analysis, only AJCC T class (HR 1.68) and node positivity (HR 2.43) remained significant predictors of disease-specific survival.

CONCLUSION

Despite socioeconomic disparities, African Americans, and Caucasians with GC had similar treatment and outcomes. African Americans presented at a younger age with higher rates of H. pylori positivity, warranting further investigation into differences in risk factors and tumor biology.

Beta-adrenergic blockade for attenuation of catecholamine surge after traumatic brain injury: a randomized pilot trial

Background

Beta-blockers have been proven in multiple studies to be beneficial in patients with traumatic brain injury. Few prospective studies have verified this and no randomized controlled trials. Additionally, most studies do not titrate the dose of beta-blockers to therapeutic effect. We hypothesize that propranolol titrated to effect will confer a survival benefit in patients with traumatic brain injury.

Methods

A randomized controlled pilot trial was performed during a 24-month period. Patients with traumatic brain injury were randomized to propranolol or control group for a 14-day study period. Variables collected included demographics, injury severity, physiologic parameters, urinary catecholamines, and outcomes. Patients receiving propranolol were compared with the control group.

Results

Over the study period, 525 patients were screened, 26 were randomized, and 25 were analyzed. Overall, the mean age was 51.3 years and the majority were male with blunt mechanism. The mean Injury Severity Score was 21.8 and median head Abbreviated Injury Scale score was 4. Overall mortality was 20.0%. Mean arterial pressure was higher in the treatment arm as compared with control (p=0.021), but no other differences were found between the groups in demographics, severity of injury, severity of illness, physiologic parameters, or mortality (7.7% vs. 33%; p=0.109). No difference was detected over time in any variables with respect to treatment, urinary catecholamines, or physiologic parameters. Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation scores all improved over time. GCS at study end was significantly higher in the treatment arm (11.7 vs. 8.9; p=0.044). Finally, no difference was detected with survival analysis over time between groups.

Conclusions

Despite not being powered to show statistical differences between groups, GCS at study end was significantly improved in the treatment arm and mortality was improved although not at a traditional level of significance. The study protocol was safe and feasible to apply to an appropriately powered larger multicenter study.

Level of evidence

Level 2—therapeutic.