US Medical-Legal Partnerships to Address Health-Harming Legal Needs: Closing the Health Injustice Gap.

The medical-legal partnership (MLP) model is emerging across the USA as a powerful tool to address the adverse social conditions underlying health injustice. MLPs embed legal experts into healthcare teams to address health-harming legal needs with civil legal remedies. We conducted a narrative review of peer-reviewed articles published between 2007 and 2022 to characterize the structure and impacts of US MLPs on patients, providers, and healthcare systems. We found that MLPs largely serve vulnerable patient populations by integrating legal experts into community-based clinical settings or children's hospitals, although patient populations and settings varied widely. In most models, healthcare providers were trained to screen patients for legal needs and refer them to legal experts. MLPs provided a wide range of services, such as assistance accessing public benefits (e.g., Social Security, Medicaid, cash assistance) and legal representation for immigration and family law matters. Patients and their families also benefited from increased knowledge about legal rights and systems. Though the evidence base remains nascent, available studies show MLPs to be associated with greater access to care, fewer hospitalizations, and improved physical and mental health outcomes. Medical and legal providers who were engaged in MLPs reported interdisciplinary learning, and healthcare systems often experienced high returns on investment through cost savings and increased Medicaid reimbursement. Many MLPs also conducted advocacy and education to effect broader policy changes related to population health and social needs. To optimize the MLP model, more rigorous research, systematic implementation practices, evaluation metrics, and sustainable funding mechanisms are recommended. Broader integration of MLPs into healthcare systems could help address root causes of health inequity among historically marginalized populations in the USA.

Exploring Experiences of Traumatic Microaggressions Toward Surgeons and Surgical Residents.

INTRODUCTION: Studies have suggested that experiences of gender and racial discrimination are widespread among surgeons and surgical residents. This study examines the relationship between experienced microaggressions and traumatic stress. METHODS: A one-time, deidentified survey was distributed over email to academic surgical societies. The survey consisted of 35 items including questions on prevalence of microaggressions, perceived job impacts as well as a shortened version of the Trauma Symptoms of Discrimination Scale. Chi-square tests and an independence test for trends were utilized to determine significance. RESULTS: We collected data from 130 participants with majority (81%) having experienced microaggressions in the workplace. On measures of worry (P < 0.001), avoidance (P = 0.012), anxiety (P = 0.004), and trouble relaxing (P = 0.002), racial/ethnic minority surgeons and trainees demonstrated significantly higher scores. With perceived job impacts, significant agreement was seen with occurrences of working harder to prove competence (P = 0.005), gaining patient confidence (P < 0.001), reduced career satisfaction (P = 0.011), work-related negative talk (P = 0.018), and burnout at work due to microaggressions (P = 0.019). Among participants who underwent behavioral modifications, female surgeons were more likely to change their nonverbal communication styles (P < 0.001) and spend more time with patients (P < 0.001). CONCLUSIONS: Experiences of microaggressions are associated with increased anxiety-related trauma symptoms in racial/ethnic minority surgeons and surgical trainees. Additionally, these experiences of microaggression can influence job satisfaction, burnout, career perceptions and workplace behaviors. As the field of surgery becomes more diverse, this study contributes to growing awareness of the role of implicit discrimination in the attrition and retention of racial/ethnic minority surgeons and female surgeons.

And Miles to Go Before We Sleep: EAST Diversity and Inclusivity Progress and Remaining Challenges.

OBJECTIVE: The aim of this study was to examine the diversity, equity, and inclusion landscape in academic trauma surgery and the EAST organization. SUMMARY BACKGROUND DATA: In 2019, the Eastern Association for the Surgery of Trauma (EAST) surveyed its members on equity and inclusion in the #EAST4ALL survey and assessed leadership representation. We hypothesized that women and surgeons of color (SOC) are underrepresented as EAST members and leaders. METHODS: Survey responses were analyzed post-hoc for representation of females and SOC in academic appointments and leadership, EAST committees, and the EAST board, and compared to the overall respondent cohort. EAST membership and board demographics were compared to demographic data from the Association of American Medical Colleges. RESULTS: Of 306 respondents, 37.4% identified as female and 23.5% as SOC. There were no significant differences in female and SOC representation in academic appointments and EAST committees compared to their male and white counterparts. In academic leadership, females were underrepresented ( P < 0.0001), whereas SOC were not ( P = 0.08). Both females and SOC were underrepresented in EAST board membership ( P = 0.002 and P = 0.043, respectively). Of EAST's 33 presidents, 3 have been white women (9%), 2 have been Black, non-African American men (6%), and 28 (85%) have been white men. When compared to 2017 AAMC data, women are well-represented in EAST's 2020 membership ( P < 0.0001) and proportionally represented on EAST's 2019-2020 board ( P > 0.05). CONCLUSIONS: The #EAST4ALL survey suggests that women and SOC may be underrepresented as leaders in academic trauma surgery. However, lack of high-quality demographic data makes evaluating representation of structurally marginalized groups challenging. National trauma organizations should elicit data from their members to re-assess and promote the diversity landscape in trauma surgery.

Review Paper on Penetrating Brain Injury: Ethical Quandaries in the Trauma Bay and Beyond.

OBJECTIVE: The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. BACKGROUND: While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. METHODS: We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. RESULTS: Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. CONCLUSIONS: Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

Nationwide Management of Trauma in Child Abuse: Exploring the Racial, Ethnic, and Socioeconomic Disparities.

OBJECTIVE: Child abuse is a major cause of childhood injury, morbidity, and death. There is a paucity of data on the practice of abuse interventions among this vulnerable population. The aim of our study was to identify the factors associated with interventions for child abuse on a national scale. METHODS: Retrospective analysis of 2017 to 2018 American College of Surgeons (ACS) Pediatric Trauma Quality Improvement Program (TQIP). All children presenting with suspected/confirmed child abuse and an abuse report filed were included. Patients with missing information regarding abuse interventions were excluded. Outcomes were abuse investigations initiated among those with abuse reports, and change of caregiver at discharge among survivors with an investigation initiated. Multivariable regression analyses were performed. RESULTS: A total of 7774 child abuse victims with an abuse report were identified. The mean age was 5±5 years, 4221 (54%) patients were White, 2297 (30%) Black, 1543 (20%) Hispanic, and 5298 (68%) had government insurance. The most common mechanism was blunt (63%), followed by burns (10%) and penetrating (10%). The median Injury Severity Score was 5 (1-12). The most common form of abuse was physical (92%), followed by neglect (6%), sexual (3%), and psychological (0.1%). The most common perpetrator of abuse was a care provider/teacher (49.5%), followed by a member of the immediate family (30.5%), or a member of the extended/step/foster family (20.0%). Overall, 6377 (82%) abuse investigations were initiated for those with abuse reports. Of these, 1967 (33%) resulted in a change of caregiver. Black children were more likely to have abuse investigated, and Black and Hispanic children were more likely to experience change of caregiver after investigations, while privately insured children were less likely to experience both. CONCLUSIONS: Significant racial, ethnic, and socioeconomic disparities exist in the nationwide management of child abuse. Further studies are strongly warranted to understand contributing factors and possible strategies to address them. LEVEL OF EVIDENCE: Level III-therapeutic/care management.

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.

Fair and equitable subject selection in concurrent COVID-19 clinical trials.

Clinical trials emerged in rapid succession as the COVID-19 pandemic created an unprecedented need for life-saving therapies. Fair and equitable subject selection in clinical trials offering investigational therapies ought to be an urgent moral concern. Subject selection determines the distribution of risks and benefits, and impacts the applicability of the study results for the larger population. While Research Ethics Committees monitor fair subject selection within each trial, no standard oversight exists for subject selection across multiple trials for the same disease. Drawing on the experience of multiple clinical trials at a single academic medical centre in the USA, we posit that concurrent COVID-19 trials are liable to unfair and inequitable subject selection on account of scientific uncertainty, lack of transparency, scarcity and, lastly, structural barriers to equity compounded by implicit bias. To address the critical gap in the current literature and international regulation, we propose new ethical guidelines for research design and conduct that bolsters fair and equitable subject selection. Although the proposed guidelines are tailored to the research design and protocol of concurrent trials in the COVID-19 pandemic, they may have broader relevance to single COVID-19 trials.

Cerebrovascular Complications in Early Survivors of Civilian Penetrating Brain Injury.

BACKGROUND: This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome. METHODS: We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome. RESULTS: Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI. CONCLUSION: Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.

Perceptions of Equity and Inclusion in Acute Care Surgery: From the #EAST4ALL Survey.

OBJECTIVES AND BACKGROUND: The aim of this study was to characterize equity and inclusion in acute care surgery (ACS) with a survey to examine the demographics of ACS surgeons, the exclusionary or biased behaviors they witnessed and experienced, and where those behaviors happen. A major initiative of the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force of the Eastern Association for the Surgery of Trauma was to characterize equity and inclusion in ACS. To do so, a survey was created with the above objectives. METHODS: A cross-sectional, mixed-methods anonymous online survey was sent to all EAST members. Closed-ended questions are reported as percentages with a cutoff of α = 0.05 for significance. Quantitative results were analyzed focusing on mistreatment and bias. RESULTS: Most respondents identified as white, non-Hispanic and male. In the past 12 months, 57.5% of females witnessed or experienced sexual harassment, whereas 48.6% of surgeons of color witnessed or experienced racial/ethnic discrimination. Sexual harassment, racial/ethnic prejudice, or discrimination based on sexual orientation/sex identity was more frequent in the workplace than at academic conferences or in ACS. Females were more likely than males to report unfair treatment due to age, appearance or sex in the workplace and ACS (P ≤ 0.002). Surgeons of color were more likely than white, non-Hispanics to report unfair treatment in the workplace and ACS due to race/ethnicity (P < 0.001). CONCLUSIONS: This is the first survey of ACS surgeons on equity and inclusion. Perceptions of bias are prevalent. Minorities reported more inequity than their white male counterparts. Behavior in the workplace was worse than at academic conferences or ACS. Ensuring equity and inclusion may help ACS attract and retain the best and brightest without fear of unfair treatment.

Pelvic Trauma: factors predicting arterial hemorrhage and the role of Angiography and preperitoneal pelvic packing.

OBJECTIVES: (1) To identify the factors predicting arterial extravasation in pelvic trauma and (2) to assess the efficacy of preperitoneal pelvic packing (PPP) in controlling arterial hemorrhage. METHODS: Institutional review board approved the retrospective study of 139 consecutive pelvic trauma patients who underwent angiographic intervention with or without prior PPP between January 2011 and December 2016. Patient demographics and presenting characteristics were recorded. Both groups of patients were combined for analysis of predictors for arterial extravasation using univariate logistic regression followed by multivariate logistic regression. Significance level was defined as p < 0.05. RESULTS: Forty-nine out of 139 patients had PPP prior to pelvic angiogram. Embolization was performed in 85 (61.2%) patients and the technical and clinical success rate was 100%. Sixty-nine (49.7%) patients had unstable Young-Burgess (Y&B) type fractures, of which 58% had arterial hemorrhage compared with 38.6% of those with stable Y&B fractures (p = 0.02). Of the patients who had PPP prior to angiogram, 28(57.1%) continued to have arterial extravasation on subsequent angiography. Unstable Y&B type fractures are independent predictors of arterial hemorrhage (OR 2.3, 95%CI 1.1 to 4.7, p = 0.02). CONCLUSION: Unstable Y&B type pelvic fractures are predictors of arterial extravasation. PPP alone is not effective for arterial hemorrhage control in pelvic trauma. Angiographic intervention remains a minimally invasive and definitive treatment of arterial hemorrhage from pelvic trauma. KEY POINTS: • Unstable Young-Burgess pelvic fractures are predictors of arterial hemorrhage in pelvic trauma. • Pelvic angiography and embolization should precede PPP wherever feasible.

Narrow- versus Broad-Spectrum Antibiotics for Simple Acute Appendicitis Treated by Appendectomy: A Post Hoc Analysis of EAST MUSTANG Study.

BACKGROUND: We sought to compare the effectiveness of narrow- versus broad-spectrum antibiotics (abx) in preventing infectious complications in adults with acute appendicitis treated with appendectomy. METHODS: In this post hoc analysis of a prospective multicenter observational study of appendicitis in adults (≥18 y) conducted from January 2017 to June 2018, we included only patients with simple appendicitis. Subjects were grouped based on receipt of broad-spectrum or narrow-spectrum abx before and/or after appendectomy. Outcomes compared were surgical site infection, intra-abdominal abscess, secondary interventions (percutaneous drainage or operation), emergency department (ED) visits, 30-d readmission, and hospital length of stay. RESULTS: A total of 2336 subjects were analyzed. In comparing narrow (n = 778) versus broad (n = 1558) groups, there were no differences in male sex (53% versus 54%, P = 0.704), white blood cell (13.0 ± 3.9 versus 13.4 ± 4.5, P = 0.05), Alvarado score (6 [5-7] versus 6 [5-7], P = 0.25), or Charlson comorbidity index (0 [0-1] versus 0 [0-1], P = 0.09). A total of 688 (29%) received postoperative abx, [184 (24%) narrow and 504 (32%) broad, P < 0.001] for a median 5 [2-7] d [42 (23%) narrow and 235 (47%) broad, P < 0.001]. There were no significant differences between narrow and broad groups in surgical site infection, intra-abdominal abscess, secondary interventions, ED visits, or hospital readmissions. CONCLUSIONS: Significant practice variation in duration and spectrum of antibiotic adjunct for surgical treatment of simple acute appendicitis treatment is evident, and broad-spectrum abx did not offer clinical advantages over narrow-spectrum abx. Restriction of antibiotic spectrum should be considered, although randomized trials are required to overcome selection bias.

Validating the ATLS Shock Classification for Predicting Death, Transfusion, or Urgent Intervention.

BACKGROUND: The Advanced Trauma Life Support (ATLS) shock classification has been accepted as the conceptual framework for clinicians caring for trauma patients. We sought to validate its ability to predict mortality, blood transfusion, and urgent intervention. MATERIALS AND METHODS: We performed a retrospective review of trauma patients using the 2014 National Trauma Data Bank. Using initial vital signs data, patients were categorized into shock class based on the ATLS program. Rates for urgent blood transfusion, urgent operative intervention, and mortality were compared between classes. RESULTS: 630,635 subjects were included for analysis. Classes 1, 2, 3, and 4 included 312,404, 17,133, 31, and 43 patients, respectively. 300,754 patients did not meet criteria for any ATLS shock class. Of the patients in class 1 shock, 2653 died (0.9%), 3123 (1.0%) were transfused blood products, and 7115 (2.3%) underwent an urgent procedure. In class 2, 219 (1.3%) died, 387 (2.3%) were transfused, and 1575 (9.2%) underwent intervention. In class 3, 7 (22.6%) died, 10 (32.3%) were transfused, and 13 (41.9%) underwent intervention. In class 4, 15 (34.9%) died, 19 (44.2%) were transfused, and 23 (53.5%) underwent intervention. For uncategorized patients, 21,356 (7.1%) died, 15,168 (5.0%) were transfused, and 23,844 (7.9%) underwent intervention. CONCLUSIONS: Almost half of trauma patients do not meet criteria for any ATLS shock class. Uncategorized patients had a higher mortality (7.1%) than patients in classes 1 and 2 (0.9% and 1.3%, respectively). Classes 3 and 4 only accounted for 0.005% and 0.007%, respectively, of patients. The ATLS classification system does not help identify many patients in severe shock.

Hidden Costs of Hospitalization After Firearm Injury: National Analysis of Different Hospital Readmission.

OBJECTIVE: To compare the risk factors and costs associated with readmission after firearm injury nationally, including different hospitals. BACKGROUND: No national studies capture readmission to different hospitals after firearm injury. METHODS: The 2013 to 2014 Nationwide Readmissions Database was queried for patients admitted after firearm injury. Logistic regression identified risk factors for 30-day same and different hospital readmission. Cost was calculated. Survey weights were used for national estimates. RESULTS: There were 45,462 patients admitted for firearm injury during the study period. The readmission rate was 7.6%, and among those, 16.8% were readmitted to a different hospital. Admission cost was $1.45 billion and 1-year readmission cost was $131 million. Sixty-four per cent of those injured by firearms were publicly insured or uninsured. Readmission predictors included: length of stay >7 days [odds ratio (OR) 1.43, P < 0.01], Injury Severity Score >15 (OR 1.41, P < 0.01), and requiring an operation (OR 1.40, P < 0.01). Private insurance was a predictor against readmission (OR 0.81, P < 0.01). Predictors of readmission to a different hospital were unique and included: initial admission to a for-profit hospital (OR 1.52, P < 0.01) and median household income ≥$64,000 (OR 1.48, P < 0.01). CONCLUSIONS: A significant proportion of the national burden of firearm readmissions is missed by not tracking different hospital readmission and its unique set of risk factors. Firearm injury-related hospitalization costs $791 million yearly, with the largest fraction paid by the public. This has implications for policy, benchmarking, quality, and resource allocation.

Geo-demographics of gunshot wound injuries in Miami-Dade county, 2002-2012.

BACKGROUND: We evaluated correlates of gunshot wound (GSW) injuries in Miami-Dade County, Florida. Firearm-related injury has previously been linked to socio- and geo-demographic indicators such as occupation, income, neighborhood and race in other metropolitan areas, but remains understudied in Miami. METHODS: We reviewed 4,547 cases from a Level I trauma center's patient registry involving an intentional firearm-related injury occurring from 2002 to 2012. During this eleven-year study period, this trauma center was the only one in Miami-Dade County, and thus representative of countywide injuries. RESULTS: The crude morbidity rate of GSW injury over the 11-year period was 15 per 100,000 persons with a crude mortality rate of 0.27 per 100,000 persons. The case fatality rate of injured patients was 15.4%. Both morbidity and mortality increased modestly over the 11-year study period. The total number of GSW patients rose annually during the study period and patients were disproportionately young, black males, though we observed higher severity of injury in white populations. Geo-demographic analysis revealed that both GSW incident locations and patient home addresses are spatially clustered in predominantly poor, black neighborhoods near downtown Miami, and that these patterns persisted throughout the study period. Using spatial regression, we observed that census tract-level GSW incidence rates (coded by home address) were associated with a census tract's proportion of black residents (P < .001), single-parent households (P < .001), and median age (P < .001) (R 2 = .42). CONCLUSIONS: These findings represent the first representative geo-demographic analysis of GSW injuries in Miami-Dade County, and offer evidence to support urgent, targeted community engagement and prevention strategies to reduce local firearm violence.

The Perceived Consequences of Gold Mining in Postwar El Salvador: A Qualitative Study.

OBJECTIVES: We investigated themes related to the health and environmental impacts of gold mining in El Salvador. METHODS: Over a 1-month period in 2013, we conducted focus groups (n = 32 participants in total) and individual semistructured interviews (n = 11) with community leaders until we achieved thematic saturation. Data collection took place in 4 departments throughout the country. We used a combination of criterion-purposive and snowballing sampling techniques to identify participants. RESULTS: Multiple themes emerged: (1) the fallacy of economic development; (2) critique of mining activities; (3) the creation of mining-related violence, with parallels to El Salvador's civil war; and (4) solutions and alternatives to mining activity. Solutions involved the creation of cooperative microenterprises for sustainable economic growth, political empowerment within communities, and development of local participatory democracies. CONCLUSIONS: Gold mining in El Salvador is perceived as a significant environmental and public health threat. Local solutions may be applicable broadly.