The Characterization of Violent Deaths Among Asian and Pacific Islander Americans.

INTRODUCTION: Health disparities in the Asian and Pacific Islander Americans (APIAs) community have not been well described, unlike non-Hispanic Black and Hispanic communities. However, there has been a rise in violence against the APIA community. This study explores and characterizes violent death by incident (e.g., homicide, suicide), weapon (e.g., firearm, strangulation), and location types among APIAs as they compare with other racial or ethnic groups. METHODS: We used the National Violent Death Reporting System from 2003 to 2018 to characterize violent deaths among APIA and compared them to all other races. We compared these racial categories in two ways. First, we compared all races as a categorical variable that included six non-Hispanic racial categories including "Other or unspecified" and "two or more races. We then created a binary variable of APIA versus All Other Races for analysis. We explored the incident type of death, substance abuse disorders, mental health history, and gang involvement among other variables. We used Chi-square tests for categorical variables and Mann-Whitney U-tests for continuous variables. RESULTS: Overall, APIAs had a unique pattern of violent death. APIAs were more likely to commit suicide (71.74%-62.21%, P<0.001) and less likely to die of homicide than other races (17.56%-24.31%, P<0.001). In the cases of homicide, APIAs were more likely to have their deaths precipitated by another crime (40.87% versus 27.87%, P < 0.001). APIAs were more than twice as likely to die of strangulation than other races (39.93%-18.06%, P<0.001). Conversely, APIAs were less likely to die by firearm than other races (29.69-51.51, P<0.001). CONCLUSIONS: APIAs have a unique pattern of violence based on analysis of data from the National Violent Death Reporting System. Our data reveal a significant difference in the incident, weapon and location type as compared to Americans of other races, which begs further inquiry into the patterns of change in time and factors that contribute to inter-racial differences in death patterns.

Safer Behind Bars? Comparing In-Custody Deaths Prior to and During Incarceration.

INTRODUCTION: This project aims to characterize trauma-associated deaths of the American incarcerated population through legal intervention (LI) or death by law enforcement officials while in custody before and during incarceration. We determined the preceding events leading to violent death, including initiation of medical care, use of restraints and force, and demographics of the victims. METHODS: We used National Violent Death Reporting System data from the years 2003-2019 to identify deaths that occurred while in custody or incarcerated, including discriminate and narrative data. Event information included weapon type, location of death, incident type, incarceration status, use of restraints, and prone positioning. RESULTS: There were 86 victims who died from LI included in the analysis. Most events occurred after incarceration. All victims in our cohort were male, and race was an associated factor for death by LI. Only 16% of victims had an education level above high school/general educational development. Death by firearm compared to other weapons was significantly more common in the in-custody but not yet incarcerated group (83% versus 42%, P ≤ 0.0001). Other associated factors included a history of mental health, physical confrontations, the belief that the victim had a weapon, and being restrained in prone positioning. CONCLUSIONS: Our study shows that racial minority victims are disproportionately affected by LI deaths. Firearms and restraint type were important factors in LI deaths. Our findings suggest that violence prevention in the justice system should focus on prevention and de-escalation across setting with specific attention to use of force and inmate access to the weapons of police, guards, and other law and justice system workers. More transparent quality data is sorely needed to adequately define and address this problem.

Immigrating to Unsafe Spaces: Unique Patterns of Homicide in Immigrant Victims Compared to Native-Born Citizens.

INTRODUCTION: Contrary to popular belief, immigrant enclaves produce less crime than other areas of the United States, yet that does not mean immigrants avoid violent crime altogether. The purpose of this project is to better characterize the victims of homicide in this population. Specifically, we sought to compare differences in victim demographics, injury patterns, and circumstances of violent death between the immigrant population and native-born victims of homicide. METHODS: We queried the National Violent Death Reporting System (NVDRS) from the years 2003-2019 for deaths in victims who were born outside of the United States. We extracted demographic information including age, race or ethnicity, means of homicide, and circumstances surrounding the event to compare immigrant to nonimmigrant deaths. RESULTS: Immigrant victims were less likely to be killed by a firearm and to have substance use or alcohol implicated. Immigrant victims were twice as likely to be killed during multiple homicide events that involved suicide of the perpetrator (2.1% to 1%, P ≤ 0.001) and to be killed by a stranger (12.9% to 6.2%, P ≤ 0.001). Immigrant victims were also more likely to be killed during the perpetration of another crime (19.1% to 15%, P ≤ 0.001), and more likely to be killed in a commercial setting such as a grocery store or retail outlet (7.6% to 2.4%, P ≤ 0.001). CONCLUSIONS: Injury prevention measures for the immigrant population require different techniques, focusing on distinct features of victimization centered on random acts in contrast to native-born citizens who tend to be victims of people they know.

Sex Differences in Violent Death During Incarceration and Legal Intervention.

INTRODUCTION: This study clarifies the differences in death during incarceration and legal intervention between males and females, delineating the differences in demographic features and the circumstances of the violent death including location, injury pattern, and perpetrator. METHODS: The data used are from the National Violent Death Reporting System database from 2003 to 2019. All victims were either in custody, in the process of custody, or in prison. Sex was coded as female or male and as assigned at birth. All analyses were conducted using SAS 9.4 software using chi-square tests, with an alpha of 0.05 to test significant differences in the circumstances of mortality and demographic characteristics for each group. RESULTS: Our findings show that suicide was the most common cause of death during incarceration for both females and males (89.8% versus 77.4%; P < 0.001). Homicide was less common in females (1.6% versus 14.8%; P < 0.001) and legal intervention only occurred in males (2.2%; P < 0.001). Male victims were more likely to be of non-White race/ethnicity compared to females, while females were more likely to be experiencing homelessness, have documented mental illness, and comorbid substance abuse. CONCLUSIONS: Victim sex is significantly associated with circumstances of violent death among the incarcerated and highlights the need for appropriate mental health and substance abuse treatment.

Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients.

INTRODUCTION: The Social Vulnerability Index (SVI) is a composite measure geocoded at the census tract level that has the potential to identify target populations at risk for postoperative surgical morbidity. We applied the SVI to examine demographics and disparities in surgical outcomes in pediatric trauma patients. METHODS: Surgical pediatric trauma patients (≤18-year-old) at our institution from 2010 to 2020 were included. Patients were geocoded to identify their census tract of residence and estimated SVI and were stratified into high (≥70th percentile) and low (<70th percentile) SVI groups. Demographics, clinical data, and outcomes were compared using Kruskal-Wallis and Fisher's exact tests. RESULTS: Of 355 patients included, 21.4% had high SVI percentiles while 78.6% had low SVI percentiles. Patients with high SVI were more likely to have government insurance (73.7% versus 37.2%, P < 0.001), be of minority race (49.8% versus 19.1%, P < 0.001), present with penetrating injuries (32.9% versus 19.7%, P = 0.007), and develop surgical site infections (3.9% versus 0.4%, P = 0.03) compared to the low SVI group. CONCLUSIONS: The SVI has the potential to examine health care disparities in pediatric trauma patients and identify discrete at-risk target populations for preventative resources allocation and intervention. Future studies are necessary to determine the utility of this tool in additional pediatric cohorts.

Suicide Among Persons Experiencing Homelessness.

INTRODUCTION: This study aims to characterize suicide and associated disparities among persons experiencing homelessness (PEH). MATERIALS AND METHODS: We reviewed suicide victims in the National Violent Death Reporting System (NVDRS) from 2003 to 2018 and compared factors surrounding suicides of PEH to factors of housed victims. We also utilized the Point-in-Time (PIT) survey (2010-2018), and census population estimates, to estimate suicide rates among PEH and the wider population. RESULTS: 1.1% of suicide victims were described as experiencing homelessness at the time of their deaths, a value that is disproportional given the overall homeless rates of 0.2% in the past decade. Compared to nonhomeless victims, PEH were more likely to be younger, Black, male, and nonveterans. PEH were significantly more likely to have an identified alcohol/substance use disorder. PEH were half as likely to die via firearm and were more likely to die in natural areas, motels, and the streets. PEH were significantly more likely to have a history of suicidal thoughts, a history of suicide attempts, and a history of disclosure of intent, particularly to health care workers. CONCLUSIONS: PEH are disproportionately overrepresented among all suicide victims, but the circumstances surrounding their deaths create opportunity for targeted interventions.

Chronic psychiatric diagnoses increase emergency department utilization following bariatric surgery.

INTRODUCTION: This study aims to evaluate the impact mental health disorders have on emergency department (ED) utilization following bariatric surgery. We hypothesize that the presence of preexisting psychiatric diagnoses is predictive of increased post-bariatric surgical ED usage as compared to a matched cohort without psychiatric comorbidities. METHODS AND PROCEDURES: We utilized the Colorado All Payers Claim Database to identify patients undergoing laparoscopic sleeve gastrectomy, gastric band, or gastric bypass, (N = 5393). Patients with preexisting diagnoses of schizophrenia or bipolar disorder (PSY), and no concomitant mental health diagnosis were included (N = 427). Patients without a psychiatric diagnosis (CON) were used for comparison. Propensity score matching in a 1:1 ratio was done matching for age, sex, BMI, procedure type, and comorbidities. Baseline ED utilization was calculated over the year preceding surgery. RESULTS: A total of 240 patients with bipolar disorder or schizophrenia were identified. After matching, baseline ED utilization was 62% higher in the PSY group (ED visits per person per month (EDVPP) of 0.17 (95%CI 0.16-0.18) in the PSY group compared to 0.10 (95%CI 0.09-0.12) in the CON group). ED utilization increased dramatically in the month following surgery for both PSY and CON groups (EDVPP 0.58 (95%CI 0.52-0.65) vs 0.34 (95%CI 0.28-0.41)), but visits returned to baseline for the CON but not PSY patients by three months after surgery (11% vs 60% above baseline, respectively). In the PSY group, ED utilization remained elevated at 18% above baseline for two years post-surgery (EDVPP 0.20 (95%CI 0.19-0.22). CONCLUSIONS: Bariatric patients with schizophrenia or bipolar disorder have higher baseline ED usage compared to a matched cohort. ED usage increases post-operatively in all patients but to a greater extent in patients with these diagnoses. Such patients would benefit from intensive outpatient follow-up to limit ED visits.

Medical Response and Factors Leading to Violent Death in the United States Incarcerated Population.

BACKGROUND: This study aims to characterize trauma-associated deaths in the United States prison system. We hypothesize that incarcerated victims are less likely to receive appropriate medical care compared to the non-incarcerated. METHODS: We utilized 2015-2017 National Violent Death Reporting System data. Victims were classified by whether they were seen by emergency medical services, in the emergency room, or hospitalized prior to death, with the latter considered higher levels of care. Propensity score matching was used to compare highest level of care received by incarcerated versus non-incarcerated victims with similar age, sex, race/ethnicity, weapon type, and state where the incident occurred. RESULTS: Of 101,054 victims, 1229 (1.2%) were incarcerated at the time of fatal injury; 64.4% died by suicide. For suicide, the proportion of minority victims was higher in the incarcerated compared to the non-incarcerated population, but the opposite was true of homicide. Firearms were more commonly used in the non-incarcerated population. After Propensity score matching, we found that incarcerated victims received higher levels of medical care following suicide (P < 0.001) while there was no difference for homicide (P = 0.28). However, when only victims injured in public settings were included, we found that incarcerated homicide victims were less likely to receive hospital-based medical care. CONCLUSIONS: Contrary to our hypothesis, overall, incarcerated victims received similar levels of medical care as compared to non-incarcerated victims following lethal injury. However, this fails to account for the highly supervised setting of prisons. Our findings reinforce that violence prevention methods should be tailored to specific populations.

Circumstances of Suicide Among Lesbian, Gay, Bisexual and Transgender Individuals.

INTRODUCTION: Suicide rates for sexual minorities are higher than the heterosexual population. The purpose of this study is to explore circumstances surrounding suicide completion to inform future intervention strategies for suicide among lesbian, gay, bisexual and transgender (LGBT) individuals. MATERIALS AND METHODS: We completed a retrospective analysis of data from the National Violent Death Reporting System (NVDRS) from 2013-2017. Victims identified as transgender were considered separately. We stratified analysis by identified sex of the victim for the LGB population. RESULTS: Of the 16,831 victims whose sexual orientation or transgender status was known: 3886 (23.1%) were identified as female, 12,945 (76.9%) were identified as male. 479 (2.8%) were identified as LGBT; of these, 53 (11%) were transgender. LGBT victims were younger than non-LGBT victims. Male LGB victims were more likely to have a history of prior suicide attempts, past or current mental illness diagnosis, and were less likely to use firearms than male heterosexual victims. Female LGB victims were more likely to have problems in an intimate partner relationship than heterosexual women, while LGB men were more likely to have problems in family or other relationships. Transgender victims were again more likely to have mental health problems and a history of prior attempts, but less likely to have intimate partner problems and more likely to have a history of child abuse. CONCLUSIONS: These results highlight the importance of promoting suicide interventions that recognize the complex intersection between stated gender, sex, and sexuality and the different cultural impacts these identities can have.

The 2020 Pandemics: Lessons Learned in Academic Surgery and Beyond.

2020 was a significant year because of the occurrence of two simultaneous public health crises: the coronavirus pandemic and the public health crisis of racism brought into the spotlight by the murder of George Floyd. The coronavirus pandemic has affected all aspects of health care, particularly the delivery of surgical care, surgical education, and academic productivity. The concomitant public health crisis of racism and health inequality during the viral pandemic highlighted opportunities for action to address gaps in surgical care and the delivery of public health services. At the 2021 Academic Surgical Congress Hot Topics session on flexibility and leadership, we also explored how our military surgeon colleagues can provide guidance in leadership during times of crisis. The following is a summary of the issues discussed during the session and reflections on the important lessons learned in academic surgery over the past year.

Using the Surgical Risk Preoperative Assessment System to Define the "High Risk" Surgical Patient.

BACKGROUND: Defining a "high risk" surgical population remains challenging. Using the Surgical Risk Preoperative Assessment System (SURPAS), we sought to define "high risk" groups for adverse postoperative outcomes. MATERIALS AND METHODS: We retrospectively analyzed the 2009-2018 American College of Surgeons National Surgical Quality Improvement Program database. SURPAS calculated probabilities of 12 postoperative adverse events. The Hosmer Lemeshow graphs of deciles of risk and maximum Youden index were compared to define "high risk." RESULTS: Hosmer-Lemeshow plots suggested the "high risk" patient could be defined by the 10th decile of risk. Maximum Youden index found lower cutoff points for defining "high risk" patients and included more patients with events. This resulted in more patients classified as "high risk" and higher number needed to treat to prevent one complication. Some specialties (thoracic, vascular, general) had more "high risk" patients, while others (otolaryngology, plastic) had lower proportions. CONCLUSIONS: SURPAS can define the "high risk" surgical population that may benefit from risk-mitigating interventions.

Demographic and Regional Factors Associated With Reporting Homicides of Transgender People in the United States.

INTRODUCTION: The American Medical Association recently declared homicides of transgender individuals an epidemic. However, transgender homicide victims are often classified as nontransgender. Our objective was to describe existing data and coding of trans (i.e., transgender) victims and to examine the risk factors for homicides of trans people relative to nontrans people across the United States. METHODS: A retrospective review of the Centers for Disease Control and Prevention's National Violent Death Reporting System for the years 2003-2018 identified victims defined as transgender either through the "transgender" variable or narrative reports. Fisher's exact tests and logistic regression models were run to compare the demographics of trans victims to those not identified as trans. RESULTS: Of the 147 transgender victims identified, 14.4% were incorrectly coded as nontrans despite clear indication of trans status in the narrative description, and 6% were coded as hate crimes. Relative to nontrans victims, trans victims were more frequently Black (54.4% versus 40.7%, P = 0.001), had a mental health condition (26.5% versus 11.3%, P < 0.001), or reported being a sex worker (9.5% versus 0.2%, P < 0.001). There were disproportionately few homicides of transgender people in the South (13.6% of trans victims versus 29.1% of nontrans victims, P < 0.001). Conversely, the West and Midwest accounted for a higher-than-expected proportion of trans victims relative to nontrans victims (23.1% of trans victims versus 16.2% of nontrans victims, P = 0.03; 24.5% of trans victims versus 16.8% of nontrans victims, P = 0.02, respectively). CONCLUSIONS: Though the murder of transgender individuals is a known public health crisis, inconsistencies still exist in the assessment and reporting of transgender status. Further, these individuals were more likely to have multiple distinct vulnerabilities. These findings provide important information for injury and violence prevention researchers to improve reporting of transgender status in the medical record and local trauma registries.

Geographic distribution of colonoscopy providers in the United States: An analysis of medicare claims data.

INTRODUCTION: Screening colonoscopy is one of the few procedures that can prevent cancer. While the majority of colonoscopies in the USA are performed by gastroenterologists, general surgeons play a key role in at-risk, rural populations. The aim of this study was to examine geographic practice patterns in colonoscopy using a nationwide Medicare claims database. METHODS AND PROCEDURES: The 2017 Medicare Provider Utilization and Payment database was used to identify physicians performing colonoscopy. Providers were classified as gastroenterologists, surgeons, ambulatory surgical centers (ASCs), or other. Rural-Urban Commuting Area classification at the zip code level was used to determine whether the practice location for an individual provider was in a rural area/small town (< 10,000 people), micropolitan area (10-50,000 people), or metropolitan area (> 50,000 people). RESULTS: Claims data from 3,861,187 colonoscopy procedures on Medicare patients were included. The majority of procedures were performed by gastroenterologists (57.2%) and ASCs (32.1%). Surgeons performed 6.8% of cases overall. When examined at a zip code level, surgeons performed 51.6% of procedures in small towns/rural areas and 21.7% of procedures in micropolitan areas. Individual surgeons performed fewer annual procedures as compared to gastroenterologists (median 51 vs. 187, p < 0.001). CONCLUSIONS: Surgeons perform the majority of colonoscopies in rural zip codes on Medicare patients. High-quality, surgical training in endoscopy is essential to ensure access to colonoscopy for patients outside of major metropolitan areas.

The Critical Intervention Screen: A Novel Tool to Determine the Use of Lights and Sirens during the Transport of Trauma Patients.

Objective: EMS use of lights and sirens has long been employed in EMS systems, despite an increased risk of motor vehicle collisions associated with their use. The specific aims of this study were to assess the current use of lights and sirens during the transport of trauma patients in a busy metropolitan area and to subsequently develop a novel tool, the Critical Intervention Screen, to aid EMS professionals tasked with making transport decisions in the presence of acute injury.Methods: This single-center, retrospective study included all patients transported to an academic Level One trauma center by ground ambulance from the scene of presumed or known injury. A subset of patients was identified as being most likely to benefit from shorter transport times if they received one of the following critical interventions within 20 minutes of emergency department arrival: intubation, thoracotomy, chest tube, blood products, central line, arterial line, REBOA, disposition to an operating room, or death. Stepwise logistic regression was employed for the development of the Critical Intervention Screen, with a subset of data retained for internal validation.Results: 1296 patients were available for analysis. Overall, 217 patients (16.7%) received a critical intervention, and 112 patients (8.6%) of those patients received a critical intervention within 20 minutes of emergency department arrival. At baseline, EMS use of lights and sirens was 91.1% sensitive and 80.3% specific for receiving a critical intervention. Stepwise logistic regression demonstrated that the need for assisted ventilation, GCS Motor < 6, and penetrating trauma to the trunk were the most predictive prehospital data for receiving at least one critical intervention. The Critical Intervention Screen, defined as having at least one of these risk factors in the prehospital setting, modestly increased sensitivity and specificity (96.4% and 87.9%, respectively) predicting the need for a critical intervention.Conclusion: These findings indicate that EMS are able to correctly identify high-acuity trauma patients, but at times employ L&S during the transport of patients with a low likelihood of receiving a time-sensitive intervention upon emergency department arrival. Therefore, the Critical Intervention Screen has the potential to reduce the use of lights and sirens and improve EMS safety.

Trauma Registry Data Collection Practices and the Impact of Hospital Data Dictionaries: A National Survey.

BACKGROUND: Trauma programs are required to collect a uniform set of trauma variables and submit data to regional, state, and or national registries. Programs may also collect unique data elements to support hospital-specific initiatives. OBJECTIVE: This study explored what additional data elements are being collected by U.S. trauma programs and the impact of having a hospital-specific data dictionary. METHODS: An anonymous, cross-sectional survey exploring what additional data are being collected, and the impact of having a hospital-specific data dictionary, was distributed by the Society of Trauma Nurses, Trauma System News, and the American College of Surgeons. The survey was open from July 2020 to September, 2020. RESULTS: There were 693 respondents from approximately 368 Level I/II trauma programs. The estimated trauma center response rate was 59.4% (n = 368/620). Level I programs had a higher response rate than Level II programs (66.9% and 53.4%, respectively).In our sample, 85.5% of responding centers collect additional data. The most common additional data collected at Level I/II programs concerned quality improvement initiatives (70.3% and 66.1%, respectively). Other commonly collected data pertained to deaths (60.6%) and complications (50.3%).Only 43% of responding centers (n = 161/368) have a hospital-specific data dictionary. Hospitals that collect additional data were more likely to have such a resource compared with those that do not (n = 147/315, 46.7% vs. n = 14/53, 26.4%, p = .01). CONCLUSION: Most trauma programs collect data outside required fields. Fewer than half define these data in a data dictionary. Centers should consider establishing a data dictionary to define data collected.

How Do Hospital-Specific Data Dictionaries Impact Competency Level With Data Collection: A National Survey.

BACKGROUND: Trauma registry staff are tasked with high-quality data collection to support program requirements. Hospital-specific data dictionaries are increasingly used to ensure accurate data collection, yet it is unknown how such a resource impacts a trauma registry team's competency with data collection. OBJECTIVE: This study sought to explore whether having a hospital-specific data dictionary affected trauma service team members' self-reported competency level with abstracting required and nonrequired data elements. METHODS: This study used an anonymous, cross-sectional survey distributed (July 2020 to September 2020) by the Society of Trauma Nurses, the American College of Surgeons, and the Trauma System News outlets to trauma registrars, trauma nurse coordinators, clinical quality specialists, program managers, program directors, and trauma research personnel. A 26-question survey was designed using a visual sliding scale from 0 to 100 to measure self-reported competence and associated variables. RESULTS: A total of 881 respondents completed the survey from at least 495 centers. Six hundred ninety-six (79.0%) respondents were from Level I or Level II programs. Several factors were associated with team members feeling highly competent in collecting data for various reporting requirements, including the level of trauma center verification, tenure working in trauma services, and the presence of a hospital-specific data dictionary. CONCLUSION: Trauma centers should consider establishing a hospital-specific data dictionary as they are associated with higher registry staff competence working with trauma registry data.

Making it Complicated: Does Disparity in Access to Care Lead to More Perforated Appendicitis?

INTRODUCTION: Delays in obtaining care may lead to perforated appendicitis, increasing risk of morbidity and mortality. We previously explored the role of social determinants in patients undergoing cholecystectomy, finding that emergent presentation is associated with neighborhood Social Vulnerability Index (SVI). We hypothesize that social vulnerability is associated with increased incidence of perforated appendicitis. METHODS: We retrospectively identified patients presenting to our urban, academic hospital with acute appendicitis during a 9-month timeframe (11/2019 - 7/2020). Patients were classified as perforated or non-perforated. Patient SVI was determined using geocoding at the census tract level. Because rates of perforation were higher in older patients, we performed a subset analysis of patients ≥ 40 years. RESULTS: 190 patients were included. Patients with perforated appendicitis (n = 48, 25%) were older and were more likely to present to a clinic versus the emergency department (P = 0.009). Perforated patients had longer delay before seeking care (56% versus 6% with > 72 hours of symptoms, P < 0.001). However, there were no differences between groups in terms of sex, race/ethnicity, insurance type, language barrier, having a primary care physician, or any of the SVI subscales. Of patients ≥ 40 years, a higher proportion were perforated (28/80, 35%) despite similar rates of delayed care. In this cohort, higher overall SVI as well as the socioeconomic status and household composition/disability subscales were associated with perforation. CONCLUSIONS: Contrary to our hypothesis, while perforation was associated with delayed care in this population, we did not find overall that social vulnerability or individual social determinants accounted for this delay.

Disparities in Emergency Versus Elective Surgery: Comparing Measures of Neighborhood Social Vulnerability.

BACKGROUND: Several composite measures of neighborhood social vulnerability exist and are used in the health disparity literature. This study assesses the performance of the Social Vulnerability Index (SVI) compared with three similar measures used in the surgical literature: Area Deprivation Index (ADI), Community Needs Index (CNI), and Distressed Communities Index (DCI). There are advantages of the SVI over these other scales, and we hypothesize that it performs equivalently. METHODS: We identified all cholecystectomies at a single, urban, academic hospital over a 9-month period. Cases were considered emergency if the patient presented and underwent surgery during that admission. We geocoded patient's addresses and assigned estimated SVI, ADI, CNI, and DCI. Cutoffs for high versus low social vulnerability were generated using Youden's index, and the scales were compared using multivariable modeling. RESULTS: Overall, 366 patients met inclusion criteria, and the majority (n = 266, 73%) had surgery in the emergency setting. On multivariable modeling, patients with high social vulnerability were more likely to undergo emergency surgery compared with those with low social vulnerability in accordance with all four scales: SVI (OR 3.24, P < 0.001), ADI (OR 3.2, P < 0.001), CNI (OR 1.90, P = 0.04), and DCI (OR 2.01, P = 0.03). The scales all had comparable predictive value. CONCLUSIONS: The SVI performs similarly to other indices of neighborhood vulnerability in demonstrating disparities between emergency and elective surgery and is readily available and updated. Because the SVI has multiple subcategories in addition to the overall measure, it can be used to stratify by modifiable factors such as housing or transportation to inform interventions.

Cholecystectomy: Exploring the Interplay Between Access to Care and Emergent Presentation.

BACKGROUND: The burden of emergency general surgery leads to higher cost and less compensation to institutions; cholecystectomy accounts for >150,000 cases/y, the highest number of emergency general surgery cases that have a potentially elective course. We hypothesize that our cholecystectomy patient pool has unique characteristics informing health care access in our area. METHODS: We retrospectively identified cholecystectomy patients at our academic hospital over a 6-mo period from January to June of 2018 and classified them as emergent or elective. We excluded pregnant patients, patients aged <18 y, and patients who had undergone another major procedure concurrently. Patient demographics and clinical course were abstracted from the medical record. RESULTS: Two hundred and sixty-seven patients were included in the study, with most patients (n = 196, 73.4%) presenting emergently. We found no differences in age, sex, or BMI between the two groups. Emergent patients were more likely to be minorities, less likely to have insurance or a primary care physician, and 25% required an interpreter. Although a greater percentage of patients in the elective setting had chronic symptoms, most emergent patients also had duration of symptoms of months to years. After multivariable analysis, insurance status, lack of a primary care provider, and chronic duration of symptoms remained significant predictors of emergent presentation. CONCLUSIONS: Our findings indicate several targets for increasing access to elective surgical care. Most patients in the emergent group experienced chronic symptoms, indicating an opportunity to prevent emergency surgical treatment. This study provides local population characterization for improvements in access to care, which could lead to decreases in emergency gallbladder surgery.

Family Can Hurt You the Most: Examining Perpetrators in Multiple Casualty Events.

INTRODUCTION: Recently, multiple-homicide events, particularly mass shootings, have become a focus of media attention. We hypothesize that many multiple homicides are related to domestic conflict and suicidality. MATERIALS AND METHODS: We analyzed multiple-homicide events (involving two or more victims) in the National Violent Death Reporting System from 2003 to 2015, including those that were followed by suicide of the perpetrator. We characterized circumstances of these events and compared victims with those found in single-homicide events. RESULTS: We identified 2425 multiple-victim incidents involving a total of 5424 homicide victims (9.3% of all homicide victims in National Violent Death Reporting System). Of these events, 14.1% (n = 341) were homicides followed by suicide of the perpetrator. Many multiple homicides involved intimate partners or family members of the victims (n = 741, 30.6%). Few of these events were related specifically to a mental health crisis (n = 39, 2.3%), resulting in the deaths of multiple strangers. Even in mass homicide events (more than four victims), many involved the death of an intimate partner or family member of the perpetrator (n = 14/31, 45.2%). Risk of homicide-suicide increased as the number of victims in the incident increased. CONCLUSIONS: In our examination of multiple-homicide events, we found that many involve the death of the intimate partner and/or family members of the perpetrator, even for events with more than four victims. Although the scenario of a perpetrator with mental health issues going on a "shooting rampage" and murdering multiple strangers is commonly invoked in mass homicide incidents, it is rare overall.