The impact of historical racism on modern gun violence: Redlining in the city of Louisville, KY

BACKGROUND

The Home Owner's Loan Corporation (HOLC) was created in 1933 to provide government backing of troubled mortgages during the Great Depression. Residential security maps were created to guide investment in over 200 US cities. Neighborhoods were assigned grades of 'A' through 'D' (with corresponding color coding of green, blue, yellow and red) to indicate desirability for investment. Neighborhoods with a high percentage of African Americans or other minorities were frequently assigned grades of 'C' or 'D'. These maps are now most associated with redlining, or the process of denial of credit for real estate investment based on race. Resulting economic disparities endure in areas of many US cities today. We hypothesized that there would be a correlation between redlined areas on the 1937 map of Louisville, KY to the prevalence of gun violence today.

METHODS

Gunshot victims (GSV) and their residential addresses within the city of Louisville were examined between 2012 and 2018. GSVs were aggregated within census block groups to approximate neighborhoods. The spatial distribution of GSVs was analyzed against the original HOLC neighborhood grade. Additional control variables adapted from the 2013-2017 American Community Survey were included to account for other possible explanations for the spatial distribution of GSVs. A zero-inflated negative binomial regression with a spatial component was used to determine incidence rate ratios (IRR) for the relative likelihood of GSVs within neighborhoods.

RESULTS

Relative to green-graded neighborhoods, red-graded neighborhoods had five times as many GSVs. This difference remained statistically significant after accounting for differences in demographic, racial, and housing characteristics of the neighborhoods.

CONCLUSION

Redlined neighborhoods within Louisville, KY in 1937 had significantly more GSVs today. The impact of historical and institutional racism on modern gun violence merits acknowledgement and further study.

Moped Crashes are Just as Dangerous as Motorcycle Crashes

Mopeds’ (MP) limited speed gives the impression that they are safer than motorcycles (MCs), but factors other than speed may contribute to crash outcome. Records of patients involved in MC or MP crashes evaluated at the University of Louisville Hospital emergency department between 2010 and 2014 were reviewed. Among patients who required hospital admission, the frequency of rib fractures, hemo- or pneumothorax, abdominal injury, extremity injury, and vertebral body fractures were greater in the MC group, whereas head and facial injuries were more common in the MP group. Positive toxicology screens were equivalent (MC 51.8% vs MP 56.8%, P = 0.25), and fewer MP riders wore helmets (33.8% vs 9.2%, P < 0.01). The injury severity score for MC was higher (15.2 vs 13.9, P = 0.039), but mortality was equivalent between groups (7.5 vs 7.6%, P = 0.98). Among patients discharged from the emergency department with minor injuries, frequency of all injury types were equivalent. Although MC patients had a statistically higher injury severity score, differences were clinically similar with equal mortality rate. Moped riders are just as likely to suffer death or serious injury after a crash compared with MC riders, and injury prevention efforts should be aimed at both groups.

Moped Crashes Are Just as Dangerous as Motorcycle Crashes

Mopeds' (MP) limited speed gives the impression that they are safer than motorcycles (MCs), but factors other than speed may contribute to crash outcome. Records of patients involved in MC or MP crashes evaluated at the University of Louisville Hospital emergency department between 2010 and 2014 were reviewed. Among patients who required hospital admission, the frequency of rib fractures, hemo- or pneumothorax, abdominal injury, extremity injury, and vertebral body fractures were greater in the MC group, whereas head and facial injuries were more common in the MP group. Positive toxicology screens were equivalent (MC 51.8% vs MP 56.8%, P = 0.25), and fewer MP riders wore helmets (33.8% vs 9.2%, P < 0.01). The injury severity score for MC was higher (15.2 vs 13.9, P = 0.039), but mortality was equivalent between groups (7.5 vs 7.6%, P = 0.98). Among patients discharged from the emergency department with minor injuries, frequency of all injury types were equivalent. Although MC patients had a statistically higher injury severity score, differences were clinically similar with equal mortality rate. Moped riders are just as likely to suffer death or serious injury after a crash compared with MC riders, and injury prevention efforts should be aimed at both groups.

Heroin-Related Compartment Syndrome: An Increasing Problem for Acute Care Surgeons

Heroin use has been increasing in the United States with the rate of heroin overdose nearly quadrupling in the last 10 years. Heroin overdose can occasionally lead to compartment syndrome (CS) because of extended periods of immobility and pressure tissue injury. Heroin-related compartment syndrome (HRCS) has previously been described, but has been limited to isolated case reports. We sought to examine our experience with HRCS in the climate of rising rates of heroin use among the general population. Medical records of all patients undergoing operative decompression for a CS at our academic medical center over a six-year period (2010-2015) were examined. Patient demographics, operation performed, and etiology were recorded. Cases of HRCS were identified, and clinical outcomes examined. A total of 213 patients undergoing fasciotomy were identified. Twenty-two of these patients had HRCS. Heroin was the second most common etiology of CS after trauma. Only one case of HRCS presented during the first three years of the study period, with the remaining 95 per cent of cases occurring within the last three years. The most common single location for HRCSs was gluteal (31.8%); 36 per cent of HRCS patients needed dialysis and 27 per cent suffered complications such as tissue loss. The incidence of HRCS has increased dramatically over the past several years and is now the second most common etiology for CS in our patient population. Patients with HRCS may present with severe manifestations of CS and different body areas affected.

Heroin-Related Compartment Syndrome: An Increasing Problem for Acute Care Surgeons

Heroin use has been increasing in the United States with the rate of heroin overdose nearly quadrupling in the last 10 years. Heroin overdose can occasionally lead to compartment syndrome (CS) because of extended periods of immobility and pressure tissue injury. Heroin-related compartment syndrome (HRCS) has previously been described, but has been limited to isolated case reports. We sought to examine our experience with HRCS in the climate of rising rates of heroin use among the general population. Medical records of all patients undergoing operative decompression for a CS at our academic medical center over a six-year period (2010–2015) were examined. Patient demographics, operation performed, and etiology were recorded. Cases of HRCS were identified, and clinical outcomes examined. A total of 213 patients undergoing fasciotomy were identified. Twenty-two of these patients had HRCS. Heroin was the second most common etiology of CS after trauma. Only one case of HRCS presented during the first three years of the study period, with the remaining 95 per cent of cases occurring within the last three years. The most common single location for HRCSs was gluteal (31.8%); 36 per cent of HRCS patients needed dialysis and 27 per cent suffered complications such as tissue loss. The incidence of HRCS has increased dramatically over the past several years and is now the second most common etiology for CS in our patient population. Patients with HRCS may present with severe manifestations of CS and different body areas affected.

Postsplenectomy vaccination guideline adherence: Opportunities for improvement

BACKGROUND AND PURPOSE

Patients undergoing splenectomy for trauma are at life-long risk for rapidly progressive septicemia. The purpose of this study was to investigate long-term patient understanding and follow-up with recommendations regarding their asplenia.

METHODS

Patients undergoing splenectomy for trauma January 2010-December 2014 were analyzed. Medical records were reviewed and telephone follow-up interviews were conducted in October-December 2015. Patients were asked a standard set of questions that included hospitalizations, awareness of infectious risks associated with asplenia, need for revaccination, and vaccines they had received since their index hospitalization.

FINDINGS

Two hundred forty-four patients underwent splenectomy during the study period. A total of 95 patients (39%) were included in the study. Thirty (32%) had been hospitalized since their trauma admission. Only 46% were aware of the risks for sepsis and the need to revaccinate. Only 7% reported having rapid access to antibiotics.

CONCLUSIONS

Despite uniform education prior to discharge, most patients undergoing splenectomy for trauma were unaware of the risks for sepsis and did not follow recommended guidelines for risk reduction.

IMPLICATIONS FOR PRACTICE

Improvements that have direct implications for advanced practice included the need to refer for vaccination, educate regarding infection risks, and facilitate rapid access to antibiotic treatment.

Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3–2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2–3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3-2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2-3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

The prevalence and impact of prescription controlled substance use among injured patients at a Level I trauma center

BACKGROUND

There has been increasing attention focused on the epidemic of prescription drug use in the United States, but little is known about its effects in trauma. The purpose of this study was to define the prevalence of prescription controlled substance use among trauma patients and determine its effects on outcome.

METHODS

A retrospective review of all patients admitted to a Level 1 trauma center from January 1, 2011, to December 31, 2011, was performed. Patients dying within 24 hours or without home medication reconciliations were excluded. Data review included preexisting benzodiazepine or narcotic use, sex, age, mechanism of injury, Injury Severity Scores (ISSs), intensive care unit (ICU) and overall length of stay, ventilator days, and overall cost. SAS version 9.3 was used for the analysis, and p ≤ 0.05 was considered significant.

RESULTS

A total of 1,700 patients met inclusion criteria. Of these, 340 (20.0%) were on prescription narcotics and/or benzodiazepines at the time of admission. Patients in the narcotic/benzodiazepine group were significantly older (48 years vs. 43 years) and more likely to be women (43.7% vs. 28.9%). There was no difference in mechanism, ISS, or the presence of head injury between groups. Both ICU length of stay (3.3 days vs. 2.1 days) and total length of stay (7.8 days vs. 6.1 days) were significantly longer in patients on outpatient narcotics and/or benzodiazepines. Excluding severely injured patients, the need for mechanical ventilation was also increased among outpatient controlled substance users (15.8% vs. 11.0%).

CONCLUSION

There is a substantial prevalence of preexisting controlled substance use (20%) among patients at our Level 1 trauma center. Preexisting controlled substance use is associated with longer total hospital and ICU stays. Among mildly to moderately injured patients, preinjury controlled substance is also associated with the need for mechanical ventilation.

LEVEL OF EVIDENCE

Prognostic study, level III.

Early pulmonary embolism after injury: a different clinical entity?

BACKGROUND

We sought to characterize pulmonary embolism (PE) occurring early after injury. We hypothesized that early PE may represent a different clinical entity than those occurring later in the post-injury period.

METHODS

All trauma patients diagnosed with PE from 2005 to 2010 were examined. PEs diagnosed within 72h of admission were compared against those occurring later.

RESULTS

19 out of 54 PEs were diagnosed early. Early PE patients had a higher rate of lower extremity fractures, a lower mean injury severity score, and a lower average length of stay. Early PE patients had a shorter average time to start of chemical prophylaxis, were less likely to have had a femoral line, and less likely to have operative intervention under general anaesthesia.

CONCLUSIONS

Early PE after trauma may occur with different underlying pathophysiology than previously thought. Further study is indicated as this has implications concerning the prevention of PE in trauma patients.

The impact of obesity on outcomes following pancreatectomy for malignancy

BACKGROUND

Obesity has previously been shown to correlate with higher stage and decreased survival in pancreatic cancer. The aim of this study was to determine the impact of obesity on operative outcomes, recurrence, and overall survival.

METHODS

A review of our 1345 patient prospective hepatopancreaticobiliary database was performed to identify patients undergoing pancreatic resection from January 1991 to August 2008 for adenocarcinoma. Obesity was defined as a body mass index (BMI) > 30 kg/m(2). Data was analyzed using Wilcoxon, t test, and chi-square methods. Survival was analyzed using log-rank analysis. Postoperative complications were assessed using a 5-point scale. P < .05 was considered significant.

RESULTS

Of 306 patients undergoing pancreatic resection for pancreatic adenocarcinoma examined, 68 were defined as obese. There was no significant difference seen in length of stay, operative time, tumor size, or node status. Obese patients had a higher operative blood loss (median 650 vs. 400 mL, P = .0008). Obese patients were more likely to suffer postoperative complications (67.6% vs. 50.4%, P = .01). There was no significant difference seen in disease-free survival or overall survival (22.1 months for obese vs. 25.6 months for nonobese, P = .5; 19.8 months for obese vs. 23.5 months for nonobese, P = .46).

CONCLUSION

Obese patients had a higher rate and greater severity of postoperative complications, with increased operative blood loss. However, obese patients did not demonstrate any significant difference in specific oncologic factors or survival. These data suggest an equivalent biologic effect of obesity on pancreatic cancer survival.

Soft tissue sarcomas may present with deep vein thrombosis

PURPOSE

To bring attention to our observation that soft tissue sarcomas may present initially as deep venous thromboses (DVTs).

METHOD

A query of our health system database (1996 to 2004) for patients diagnosed with soft tissue sarcomas and DVTs was undertaken. Patient medical records were reviewed to select those patients whose DVT occurred before the diagnosis of their tumor. Patient demographics, tumor classification, presentation, and outcome were noted.

RESULTS

Six of 19 patients were identified (four men, two women; aged 41 to 85 years). All tumors occurred in the lower extremities. All DVTs occurred in the same extremity as the tumor. Pathology specimens indicated four different types of sarcomas. In five cases, sarcoma diagnosis was delayed as treatment of the DVT occurred. In one, a mass was seen on the initial venous duplex screen. Four are deceased, one remains in treatment, and one was lost to follow-up. The average length of follow-up was 10 months.

CONCLUSION

Soft tissue sarcomas can initially present as, or even be misdiagnosed as, DVT. Given a delay in diagnosis adversely affects prognosis, it is important that physicians be vigilante for associated tumors when evaluating for suspected DVT.