Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients

Importance

Civilian trauma centers have revived interest in whole-blood (WB) resuscitation for patients with life-threatening bleeding. However, there remains insufficient evidence that the timing of WB transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome.

Objective

To evaluate whether earlier timing of first WB transfusion is associated with improved survival at 24 hours and 30 days for adult trauma patients presenting with severe hemorrhage.

Design, Setting, and Participants

This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019, to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. Patients with burns, prehospital cardiac arrest, deaths within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from January 3 to October 2, 2023.

Exposure

Patients who received WB as an adjunct to MTP (earlier) compared with patients who had yet to receive WB as part of MTP (later) at any given time point within 24 hours of ED arrival.

Main Outcomes and Measures

Primary outcomes were survival at 24 hours and 30 days.

Results

A total of 1394 patients met the inclusion criteria (1155 male [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included profoundly injured patients (median Injury Severity Score, 27 [IQR, 17-35]). A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion. Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with improved survival at 24 hours (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003). Similarly, the survival benefit of earlier WB transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < .001).

Conclusions and Relevance

In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival was associated with improved survival in patients presenting with severe hemorrhage. The survival benefit was noted shortly after transfusion. The findings of this study are clinically important as the earlier timing of WB administration may offer a survival advantage in actively hemorrhaging patients requiring MTP.

Changes in Medical Student Perceptions of Surgery Are Sustainable Through Focused Preclinical Surgical Exposure

OBJECTIVE

Many medical students hold negative perceptions about the surgical field that deter them from pursuing surgical training. We hypothesize that these perceptions can be sustainably changed with preclinical surgical education.

DESIGN

Students were administered a 10-question survey before the educational experience, immediately after completing the experience, and 1-3 years later. Survey questions focused on perceptions about surgery. Changes in responses over time were measured and analyzed.

SETTING

The study was performed in the setting of a voluntary preclinical surgical education experience.

PARTICIPANTS

Surveys were administered to 217 first-year medical students who all participated in the preclinical surgical education experience from 2017 to 2019. Follow-up surveys were administered to all cohorts simultaneously and anonymously via email.

RESULTS

Nine of the ten questions demonstrated statistically significant changes in perceptions from pre-experience to immediately post-experience (p < 0.048). Though attenuation was seen over time, changes in perception regarding the workload and time investment of surgical training, the role of women in surgery, and the relationships between surgeons and their patients were sustained over time (p < 0.044).

CONCLUSIONS

The results indicated that our model of surgical education could effect long-term changes in negative perceptions about the surgical field. Many of these negative perceptions are highly concerning to medical students. As such, success in changing perceptions about length and difficulty of training, gender inclusivity, and patient-centered care in surgery is important in increasing student interest in the surgical field. This becomes relevant in the current climate of a nationwide shortage of surgeons and the need to better attract students to this profession.

Disparities in Utilization of Ambulatory Cholecystectomy: Results From Three States

BACKGROUND

Inpatient cholecystectomy is associated with higher cost and morbidity relative to ambulatory cholecystectomy, yet the latter may be underutilized by minority and underinsured patients. The purpose of this study was to examine the effects of race, income, and insurance status on receipt of and outcomes following ambulatory cholecystectomy.

MATERIALS AND METHODS

Retrospective observational cohort study of patients 18-89 undergoing cholecystectomy for benign indications in Florida, Iowa, and New York, 2011-2014 using administrative databases. The primary outcome of interest was odds of having ambulatory cholecystectomy; secondary outcomes included intraoperative and postoperative complications, and 30-day unplanned admissions following ambulatory cholecystectomy.

RESULTS

Among 321,335 cholecystectomies, 190,734 (59.4%) were ambulatory and 130,601 (40.6%) were inpatient. Adjusting for age, sex, insurance, income, residential location, and comorbidities, the odds of undergoing ambulatory versus inpatient cholecystectomy were significantly lower in black (aOR = 0.71, 95% CI [0.69, 0.73], P< 0.001) and Hispanic (aOR = 0.71, 95% CI [0.69, 0.72], P< 0.001) patients compared to white patients, and significantly lower in Medicare (aOR = 0.77, 95% CI [0.75, 0.80] P < 0.001), Medicaid (aOR = 0.56, 95% CI [0.54, 0.57], P< 0.001) and uninsured/self-pay (aOR = 0.28, 95% CI [0.27, 0.28], P< 0.001) patients relative to privately insured patients. Patients with Medicaid and those classified as self-pay/uninsured had higher odds of postoperative complications and unplanned admission as did patients with Medicare compared to privately insured individuals.

CONCLUSIONS

Racial and ethnic minorities and the underinsured have a higher likelihood of receiving inpatient as compared to ambulatory cholecystectomy. The higher incidence of postoperative complications in these patients may be associated with unequal access to ambulatory surgery.

The Impact of Residential Racial Segregation on Non-Small Cell Lung Cancer Treatment and Outcomes

BACKGROUND

Despite decreases in lung cancer incidence, racial disparities in diagnosis and treatment persist. Residential segregation and structural racism have effects on socioeconomic status for black people, affecting healthcare access. This study aims to determine the impact of residential segregation on racial disparities in non-small cell lung cancer (NSCLC) treatment and mortality.

METHODS

Patient data were obtained from Surveillance, Epidemiology, and End Results Program (SEER) database for black and white patients diagnosed with NSCLC from 2004-2016 in the 100 most populous counties. Regression models were built to assess outcomes of interest - stage at diagnosis and surgical resection of disease. Predicted margins assessed impact of index of dissimilarity (IoD) on these disparities. Competing risk regressions for black and white patients in highest and lowest quartiles of IoD were used to assess cancer-specific mortality.

RESULTS

Our cohort had 193,369 white and 35,649 black patients. Black patients were more likely to be diagnosed at advanced stage than white patients with increasing IoD. With increasing IoD, black patients were less likely to undergo surgical resection than white. Disparities were eliminated at low IoD. Black patients at high IoD had lower cancer-specific survival.

CONCLUSIONS

Black patients were more likely to present at advanced disease, were less likely to receive surgery for early stage, and had higher cancer-specific mortality at higher IoD. Our findings highlight the impact of structural racism and residential segregation on NSCLC outcomes. Solutions to these disparities must come from policy reforms to reverse residential segregation and deleterious socioeconomic effects of discriminatory policies.

The impact of racial residential segregation on prostate cancer diagnosis and treatment

OBJECTIVES

To examine the effects of racial residential segregation and structural racism on the diagnosis, treatment, and outcomes of patients with prostate cancer.

PATIENTS AND METHODS

This retrospective cohort study examined men diagnosed with prostate cancer between 2005 and 2015. We collected data from Black and White men, aged ≥30 years, living within the 100 most populous counties participating in the Surveillance, Epidemiology, and End Results programme, a nationally representative dataset. The racial Index of Dissimilarity, a validated measure of segregation, was the primary exposure of interest. Outcomes of interest included advanced stage at diagnosis (Stage IV), surgery for localised disease (Stage I-II), and 10-year overall and cancer-specific survival. Multivariable Poisson regression analyses with robust error variance estimated the relative risk (RR) of advanced stage at diagnosis and surgery for localised disease at differing levels of segregation. Survival analysis was performed using competing hazards analysis.

RESULTS

Multivariable models estimating stage at diagnosis showed that the disparities between Black and White men disappeared at low levels of segregation. Disparities in receiving surgery for localised disease persisted across all levels of segregation. In racially stratified analyses, segregation had no effect on stage at diagnosis or surgical resection for Black patients. White patients saw a 56% (RR 0.42, P < 0.001) reduced risk of presenting at advanced stage and 20% increased likelihood (RR 1.20, P < 0.001) of surgery for localised disease. Black patients in the lowest segregation areas had the lowest overall mortality, but the highest cancer-specific mortality.

CONCLUSIONS

Our study provides evidence that residential segregation has a significant impact on Black-White disparities in prostate cancer, likely through improved outcomes for White patients and worse outcomes for Black patients in more segregated areas. These findings suggest that mitigating segregation and the downstream effects of socioeconomic factors could alleviate these disparities.

Association of Race, Health Insurance Status, and Household Income With Location and Outcomes of Ambulatory Surgery Among Adult Patients in 2 US States

Importance

The receipt of surgery in freestanding ambulatory surgery centers (ASCs) is often less costly compared with surgery in hospital-based outpatient departments. Although increasing numbers of surgical procedures are now being performed in freestanding ASCs, questions remain regarding the existence of disparities among patients receiving care at ASCs.

Objective

To examine the association of patient race, health insurance status, and household income with the location (ASC vs hospital-based outpatient department) of ambulatory surgery.

Design, Setting, and Participants

This cohort study used data from the State Ambulatory Surgery and Services Databases of the Healthcare Cost and Utilization Project to perform a secondary analysis of patients who received ambulatory surgery in New York and Florida between 2011 and 2013. Patients aged 18 to 89 years who underwent 12 different types of ambulatory surgical procedures were included. Data were analyzed from December 2018 to June 2019.

Main Outcomes and Measures

Receipt of surgery at a freestanding ASC and 30-day unplanned hospital visits after ambulatory surgery.

Results

A total of 5.6 million patients in New York (57.4% female; 68.9% aged ≥50 years; and 62.5% White) and 7.5 million patients in Florida (57.3% female; 77.4% aged ≥50 years; 74.3% White) who received ambulatory surgery were included in the analysis. After adjusting for age, comorbidities, health insurance status, household income, location of surgery, and type of surgical procedure, the likelihood of receiving ambulatory surgery at a freestanding ASC was significantly lower among Black patients (adjusted odds ratio [aOR], 0.82; 95% CI, 0.81-0.83; P < .001) and Hispanic patients (aOR, 0.78; 95% CI, 0.77-0.79; P < .001) compared with White patients in New York. This likelihood was also lower among Black patients (aOR, 0.65; 95% CI, 0.65-0.66; P < .001) compared with White patients in Florida. Public health insurance coverage was associated with a significantly lower likelihood of receiving ambulatory surgery at freestanding ASCs in both New York and Florida, particularly among patients with Medicaid (in New York, aOR, 0.22; 95% CI, 0.22-0.22; P < .001; in Florida, aOR, 0.40; 95% CI, 0.40-0.41; P < .001) and Medicare (in New York, aOR, 0.46; 95% CI, 0.46-0.46; P < .001; in Florida, aOR, 0.67; 95% CI, 0.66-0.67; P < .001).

Conclusions and Relevance

Differences in the use of freestanding ASCs were found among Black patients and patients with public health insurance. Further exploration of the factors underlying these differences will be important to ensure that all populations have access to the increasing number of freestanding ASCs.

The Intersection of Gender and Resuscitation Leadership Experience in Emergency Medicine Residents: A Qualitative Study

OBJECTIVES

The objective was to examine emergency medicine (EM) residents' perceptions of gender as it intersects with resuscitation team dynamics and the experience of acquiring resuscitation leadership skills.

METHODS

This was an exploratory, qualitative study using grounded theory and a purposive sample of postgraduate year (PGY) 2-4 EM residents who function as resuscitation team leaders in two urban EM programs. One-on-one interviews were conducted by a single experienced researcher. Audiotaped interviews were transcribed and deidentified by two research assistants. A research team composed of a PhD educational researcher, a research nurse, an MPH research assistant, and an EM resident reviewed the transcripts and coded and analyzed data using MAXQDA v12. Themes and coding schema were discussed until consensus was reached. We used member checking to assess the accuracy of our report and to confirm that the interpretations were fair and representative.

RESULTS

Theme saturation was reached after interviewing 16 participants: 10 males and 6 females. The three major themes related to gender that emerged included leadership style, gender inequality, and relationship building. Both male and female residents reported that a directive style was more effective when functioning in the resuscitation leadership role. Female residents more often expressed discomfort with a directive style of leadership, preferring a more communicative and collaborative style. Both female and male residents identified several challenges as disproportionately affecting female residents, including negotiating interactions with nurses more and "earning the respect" of the team members.

CONCLUSIONS

Residents acknowledged that additional challenges exist for female residents in becoming resuscitation team leaders. Increasing awareness in residency program leadership is key to affecting change to ensure all residents are trained in a similar manner, while also addressing gender-specific needs of residents where appropriate. We present suggestions for addressing these barriers and incorporating discussion of leadership styles into residency training.

Socially Responsible Surgery: Building Recognition and Coalition

IMPORTANCE

Socially responsible surgery (SRS) integrates surgery and public health, providing a framework for research, advocacy, education, and clinical practice to address the social barriers of health that decrease surgical access and worsen surgical outcomes in underserved patient populations. These patients face disparities in both health and in health care, which can be effectively addressed by surgeons in collaboration with allied health professionals.

OBJECTIVE

We reviewed the current state of surgical access and outcomes of underserved populations in American rural communities, American urban communities, and in low- and middle-income countries.

EVIDENCE REVIEW

We searched PubMed using standardized search terms and reviewed the reference lists of highly relevant articles. We reviewed the reports of two recent global surgery commissions.

CONCLUSION

There is an opportunity for scholarship in rural surgery, urban surgery, and global surgery to be unified under the concept of SRS. The burden of surgical disease and the challenges to management demonstrate that achieving optimal health outcomes requires more than excellent perioperative care. Surgeons can and should regularly address the social determinants of health experienced by their patients. Formalized research and training opportunities are needed to meet the growing enthusiasm among surgeons and trainees to develop their practice as socially responsible surgeons.

Implementation of a Novel Structured Social and Wellness Committee in a Surgical Residency Program: A Case Study

This article provides a theoretical and practical rational for the implementation of an innovative and comprehensive social wellness program in a surgical residency program at a large safety net hospital on the East Coast of the United States. Using basic needs theory, we describe why it is particularly important for surgical residency programs to consider the residents sense of competence, autonomy, and belonging during residence. We describe how we have developed a comprehensive program to address our residents’ (and residents’ families) psychological needs for competence, autonomy, and belongingness.

Medical emergency team response for the non-hospitalized patient

OBJECTIVES

Rapid response systems (RRS) evolved to care for deteriorating hospitalized patients outside of the ICU. However, emergent critical care needs occur suddenly and unexpectedly throughout the hospital campus, including areas with non-hospitalized persons. The efficacy of RRS in this population has not yet been described or tested. We hypothesize that non-hospitalized patients accrue minimal benefit from ICU physician participation in the RRS.

DESIGN

A retrospective review of all RRS events in non-hospitalized patients for a 28 month period was performed in a large, urban university medical center. Location, patient type and age, activation trigger, interventions performed, duration of event and disposition were recorded. Admission diagnosis and length of stay were also recorded for patients admitted to the hospital.

SETTING

Academic medical center.

PATIENTS

Non-hospitalized persons requiring evaluation by the medical emergency team.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were a total of 1778 RRS activations during the study period. 232 (13%) of activations were for non-hospitalized patients. The patient cohort consisted of outpatients, visitors, and staff. Triggers for RRS activation were neurologic change (42%), cardiac (27%), respiratory (16%), and staff concerns (16%). The mean duration of the response was 38 min. The most common interventions performed included administration of oxygen (46%), intravenous fluids (13%) and dextrose (6%). 82% of patients were taken to the emergency department and 32% of the ED cohort were admitted to the hospital.

CONCLUSIONS

Perceived emergencies in non-hospitalized patients occur commonly but require minimal emergent intervention. Restriction of critical care physician involvement to inpatient deteriorations should be considered when designing a RRS. Future studies are needed to evaluate the utility of non-physician provider led rapid response teams with protocol-driven interventions for similar populations.

Lactate in Trauma: A Poor Predictor of Mortality in the Setting of Alcohol Ingestion

Resuscitation end point markers such as lactate and base deficit (BD) are used in trauma to identify and treat a state of compensated shock. Lactate and BD levels are also elevated by alcohol. In blunt trauma patients with positive blood alcohol levels, lactate may be a poor indicator of injury. Retrospective data were collected on 1083 blunt trauma patients with positive blood alcohol levels admitted a Level I trauma center between 2003 and 2006. Patients were stratified by Injury Severity Score, age, gender, and Glasgow Coma Score. Logistic regression analyses were used to assess lactate and BD as independent risk factors for mortality. Seventy-four per cent of patients had an abnormal lactate level compared with 28 per cent with abnormal BD levels. In patients with mild injury, lactate levels were abnormal in more than 70 per cent of patients compared with less than 20 per cent of patients with abnormal BD levels. Linear regression showed lactate is not a significant predictor of mortality. Regardless of Injury Severity Score, lactate appeared to be more often abnormal than BD in the setting of alcohol ingestion. Additionally, because BD, and not lactate, was shown to be an independent predictor of mortality, lactate may not be a reliable marker of end point resuscitation in this patient population.

Lactate in trauma: a poor predictor of mortality in the setting of alcohol ingestion

Resuscitation end point markers such as lactate and base deficit (BD) are used in trauma to identify and treat a state of compensated shock. Lactate and BD levels are also elevated by alcohol. In blunt trauma patients with positive blood alcohol levels, lactate may be a poor indicator of injury. Retrospective data were collected on 1083 blunt trauma patients with positive blood alcohol levels admitted a Level I trauma center between 2003 and 2006. Patients were stratified by Injury Severity Score, age, gender, and Glasgow Coma Score. Logistic regression analyses were used to assess lactate and BD as independent risk factors for mortality. Seventy-four per cent of patients had an abnormal lactate level compared with 28 per cent with abnormal BD levels. In patients with mild injury, lactate levels were abnormal in more than 70 per cent of patients compared with less than 20 per cent of patients with abnormal BD levels. Linear regression showed lactate is not a significant predictor of mortality. Regardless of Injury Severity Score, lactate appeared to be more often abnormal than BD in the setting of alcohol ingestion. Additionally, because BD, and not lactate, was shown to be an independent predictor of mortality, lactate may not be a reliable marker of end point resuscitation in this patient population.

Elderly Patients with Pelvic Fracture: Interventions and Outcomes

We examined the outcome of elderly trauma patients with pelvic fractures. Patients 65 years of age and older (elderly) with pelvic fractures were retrospectively compared with patients younger than 65 years with pelvic fractures and also with elderly patients without fracture. Over the study period, 1223 patients sustained a pelvic fracture (younger than 65 years, n = 1066, 87.2%; elderly, n = 157,12.8%). These patients were also compared with 1770 elderly patients with blunt trauma without fracture. Although the pelvic fracture patients were equally matched for Injury Severity Score (21.2 ± 13.4 nonelderly vs 20.5 ± 13.6 elderly), hospital length of stay was increased in the elderly (12.5 ± 13.1 days vs 11.5 ± 14.1 days) and they had a higher mortality rate (20.4% [32 of 157] vs 8.3% 88 of 1066]). The elderly without fracture also had a higher mortality rate when compared with the younger patients (10.9% [191 of 1760]; P < 0.03). The elderly were more likely to die from multisystem organ failure (25.0% [eight of 32] vs 10.2% [nine of 88]), whereas the nonelderly group was more likely to die from exsanguination (45.5% [40 of 88] younger than 65 years vs 21.9% [seven of 32] 65 years or older; P < 0.05). Elderly patients with pelvic fracture have worse outcomes than their younger counterparts despite aggressive management at a Level I trauma center.

Hyaluronan in human acute and chronic dermal wounds

There is growing interest in the relationship of hyaluronan and inflammation in a number of physiologic processes including wound healing. The objective of this study was to make a quantitative comparison of inflammation and hyaluronan expression in human normal healing open wounds and in pressure ulcers. Using an open dermal wound model, myeloperoxidase activity was found to peak at day 3. Hyaluronan levels showed a bimodal distribution with transient peaks occurring on days 1 and 7. Mean levels of myeloperoxidase activity in pressure ulcers were significantly higher than at any time in the acute wounds, whereas hyaluronan levels were significantly lower than at any time in the acute wounds. Levels of hyaluronidase activity increased slightly in the postwound period. Hyaluronidase activity in pressure ulcers was significantly elevated compared with the acute wounds. These results suggest a role for increased enzymatic degradation of hyaluronan as a function of inflammation during wound repair. This is the first reported quantitative examination of hyaluronan expression in human acute dermal wounds and in chronic pressure ulcers.