Nearly 20 Years Since the Federal Ban: Can State-Level Assault Weapon Prohibitions Fill the Void? Comparative Analysis of Case Fatality and Assault Weapon Recovery in States With and Without an Assault Weapon Ban.

INTRODUCTION: Few states established assault weapon bans (AWBs) after the federal AWB expired. The effectiveness of state AWBs as well as neighboring state legislation, in reducing the local prevalence of assault weapons (AWs) or in reducing overall shooting lethality is unknown. METHODS: We queried the Gun Violence Archive (2014-2021) to identify US firearm injuries and fatalities. Shooting case fatality rates were compared among states with and without AWBs, as reported in the State Firearm Laws Database. Data on recovered firearms was obtained from the ATF Firearms Trace Database and used to estimate weapon prevalence. Recovered firearms were classified as AWs based on caliber (7.62 mm, 5.56 mm, 0.223 cal). We performed spatially weighted linear regression models, with fixed effects for state and year to assess the association between geographically clustered state legislation and firearm outcomes. RESULTS: From 2014 to 2021, the US shooting victim case fatality rate was 8.06% and did not differ among states with and without AWBs. The proportion of AWs to total firearms was 5.0% in states without an AWB and 6.0% in states with an AWB (mean difference [95% CI] = -0.8% [-1.6% to -0.2%], P = 0.03). Most recovered firearms in AWB states originated from non-AWB states. On adjusted models, there was no association between state-level AWB and firearm case fatality; however, adjacency to states with an AWB was associated with lower case fatality (P < 0.001). Clustered AWB states with shared borders had lower AW prevalence and fatality rates than the rest of the US. CONCLUSIONS: Isolated state AWBs are not inversely associated with shooting case fatality rates nor the prevalence of AWs, but AWBs among multiple neighboring states may be associated with both outcomes.

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.

Timing of venous thromboembolism prophylaxis initiation and complications in polytrauma patients with high-risk bleeding orthopedic interventions: A nationwide analysis.

INTRODUCTION: There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide. METHODS: We performed a retrospective cohort study of trauma patients 18 years or older who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons-verified trauma centers using the 2019-2020 American College of Surgeons Trauma Quality Improvement Program databank. We excluded patients with a competing risk of nonorthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared with VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, deep venous thromboembolism, and pulmonary embolism rates. RESULTS: The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (interquartile range, 18-44 hours). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (adjusted odds ratio, 2.02; 95% confidence interval, 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (hazard ratio, 0.90; 95% confidence interval, 0.62-1.34). CONCLUSION: Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic reintervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The evolution and development of a robotic acute care surgery program.

BACKGROUND: Acute care surgeons perform more than 850,000 operations annually on emergency general surgery patients in the United States. Emergency general surgery conditions are associated with a disproportionate excess of patient complications and death. Innovative quality improvement strategies have focused on addressing the excess morbidity and mortality among this patient population. Minimally invasive surgical techniques have been shown to reduce the burden experienced by emergency general surgery patients. Still, limited adoption by acute care surgeons has restricted this application's potential. An institutional robotics acute care surgery program provides acute care surgeons additional opportunities to expand minimally invasive surgery access to emergency general surgery patients irrespective of the time or day of the week. METHODS: A robotics acute care surgery program was developed and implemented at a high-volume academic institution within the division of trauma and acute care surgery. RESULTS: Three attending surgeons and two fellows within the trauma and acute care surgery division had successfully completed a defined robotics clinical pathway. As a result, around-the-clock use of a robotic surgical platform for emergency general surgery cases was implemented with routine use by trained robotic acute care surgeons and practicing fellows. CONCLUSION: The advancement of robotic surgical technology has opened new avenues for surgical application in the emergency setting. The development of a robotic acute care surgery program allows acute care surgeons to diversify their practice while providing greater access to minimally invasive approaches for emergency general surgery patients.

Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers.

Importance: Whole-blood (WB) resuscitation has gained renewed interest among civilian trauma centers. However, there remains insufficient evidence that WB as an adjunct to component therapy-based massive transfusion protocol (WB-MTP) is associated with a survival advantage over MTP alone in adult civilian trauma patients presenting with severe hemorrhage. Objective: To assess whether WB-MTP compared with MTP alone is associated with improved survival at 24 hours and 30 days among adult trauma patients presenting with severe hemorrhage. Design, Setting, and Participants: This retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2017, and December 31, 2018, included adult trauma patients with a systolic blood pressure less than 90 mm Hg and a shock index greater than 1 who received at least 4 units of red blood cells within the first hour of emergency department (ED) arrival at level I and level II US and Canadian adult civilian trauma centers. Patients with burns, death within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from February 2022 to September 2022. Exposures: Resuscitation with WB-MTP compared with MTP alone within 24 hours of ED presentation. Main Outcomes and Measures: Primary outcomes were survival at 24 hours and 30 days. Secondary outcomes selected a priori included major complications, hospital length of stay, and intensive care unit length of stay. Results: A total of 2785 patients met inclusion criteria: 432 (15.5%) in the WB-MTP group (335 male [78%]; median age, 38 years [IQR, 27-57 years]) and 2353 (84.5%) in the MTP-only group (1822 male [77%]; median age, 38 years [IQR, 27-56 years]). Both groups included severely injured patients (median injury severity score, 28 [IQR, 17-34]; median difference, 1.29 [95% CI, -0.05 to 2.64]). A survival curve demonstrated separation within 5 hours of ED presentation. WB-MTP was associated with improved survival at 24 hours, demonstrating a 37% lower risk of mortality (hazard ratio, 0.63; 95% CI, 0.41-0.96; P = .03). Similarly, the survival benefit associated with WB-MTP remained consistent at 30 days (HR, 0.53; 95% CI, 0.31-0.93; P = .02). Conclusions and Relevance: In this cohort study, receipt of WB-MTP was associated with improved survival in trauma patients presenting with severe hemorrhage, with a survival benefit found early after transfusion. The findings from this study are clinically important as this is an essential first step in prioritizing the selection of WB-MTP for trauma patients presenting with severe hemorrhage.

A tale of two cities: Policing and firearm homicides in Boston and Philadelphia.

BACKGROUND: Recent political movements have raised questions about the effectiveness of police funding, but the impact of law enforcement budgets on firearm violence is unknown. We hypothesized that department funding and measures of police activity would be associated with decreased shootings and firearm homicides (FHs) in two major cities with different police funding patterns. METHODS: We collected data from the following sources: district attorney's offices, police departments, Federal Bureau of Investigation Uniform Crime Reporting program, the Centers for Disease Control, the Annual Survey of Public Employment and Payroll, and the American Community Survey. Data included demographics, police department budgets, number of officers, homicide clearance rates, firearms recovered, shootings, and FHs, 2015 to 2020. Totals were normalized to population and number of shootings. We used panel linear regression to measure associations between policing variables, shootings, and FHs while adjusting for covariates. RESULTS: Firearm homicides significantly increased in Philadelphia. In Boston, the trend was less clear, although there was an increase in 2020. Police budget normalized to shootings trended toward a decrease in Philadelphia and an increase in Boston. The number of firearms recovered annually appeared to increase in Boston but peaked midstudy in Philadelphia. In multivariable analyses, police budget was associated with neither shootings nor FHs. However, increased firearm recovery was associated with lower shooting ( ß = -0.0004, p = 0.022) and FH ( ß = -0.00005, p = 0.004) rates. CONCLUSION: Philadelphia and Boston demonstrated differences in police funding, 2015 to 2020. While budget is not associated with shootings or FHs, firearm recovery is suggesting that removal of firearms from circulation remains key. The impact this has on vulnerable populations requires further investigation. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Regenerative Medicine: lessons from Mother Nature.

Regenerative medicine strategies for the restoration of functional tissue have evolved from the concept of ex vivo creation of engineered tissue toward the broader concept of in vivo induction of functional tissue reconstruction. Multidisciplinary approaches are being investigated to achieve this goal using evolutionarily conserved principles of stem cell biology, developmental biology and immunology, current methods of engineering and medicine. This evolution from ex vivo tissue engineering to the manipulation of fundamental in vivo tenets of development and regeneration has the potential to capitalize upon the incredibly complex and only partially understood ability of cells to adapt, proliferate, self-organize and differentiate into functional tissue.