A cost effectiveness analysis of two treatment strategies for trigeminal neuralgia in Ontario.

Background: Trigeminal neuralgia (TN) is a debilitating disease with an annual incidence of approximately 4-27/100,000. In Ontario, over 2000 patients receive interventions for profound pain, including medical and surgical therapies. The global expected cost of these approaches is unknown. This study aims to analyze the cost-effectiveness of one surgical therapy, microvascular decompression (MVD), compared with the best medical therapy (carbamazepine) as first-line therapy. Methods: Costs were gathered from the Canadian Institute for Health Information, Ontario Drug Benefit Formulary, and Ontario Ministry of Health Schedule of Benefits for Physician Services. Academic literature was used to estimate unavailable items. A cost-benefit Markov model was created for each strategy with literature-based rates for annual cycles from years 1 to 5, followed by a linear recurrent cycle from years 6 to 10. Incremental cost-effectiveness ratios (ICERs) were calculated based on the incremental cost in 2022 Canadian Dollars (CAD) per pain-free year. Results: Base case cost per patient was $10,866 at 10 years in the "MVD first" group and $10,710 in the "carbamazepine first" group. Ten-year ICER was $1,104 for "MVD first," with strict superiority beyond this time point. One-way deterministic sensitivity analysis for multiple factors suggested the highest cost variability and ICER variability were due to surgery cost, medication failure rate, and medication cost. Conclusion: Economic benefit is established for a "MVD first" strategy in the Ontario context with strict superiority beyond the 10-year horizon. If a cost-effectiveness threshold of $50,000 per pain-controlled year is used, the benefit is established at 4 years.

Surgical Management of Meningiomas Involving the Torcula, Transverse Sinus, and Jugular Bulb: A Technical Note and Review of the Literature.

Meningiomas that invade the confluens sinuum are rare and require extensive preoperative planning. Here, we describe the surgical and radio-oncological management of an aggressive large occipital meningioma invading the superior sagittal sinus, torcula, right and left transverse sinus down to the level of the jugular bulb in a 21-year-old female patient. Details of the surgical approach are presented to highlight the planned staged resection of this tumor at the level of the torcula to initially debulk the lesion while preserving venous outflow through the patent's sinus. Once the tumor fully occluded the confluens, a second-stage en bloc resection ensued. Postsurgical adjuvant radiation therapy was delivered via fractionated external beam therapy which has provided local control of the tumor since. This case is being discussed in the context of the pertinent literature to demonstrate the highly complex interdisciplinary and staged management of partially intravascular meningiomas involving the major venous sinuses.

Rates of cerebrospinal fluid leak and pseudomeningocele formation after posterior fossa craniotomy versus craniectomy: A systematic review and meta-analysis.

Background: Postoperative cerebrospinal fluid (CSF) leak is a major concern after posterior fossa surgery with significant clinical implications. It has been postulated that replacing the bone flap, performing a craniotomy, would reinforce the surgical closure and decrease rates of CSF leak. This systematic review and meta-analysis compared the rate of CSF leak after posterior fossa craniotomies versus craniectomies. Methods: Three databases were searched for English studies comparing the primary outcome, rate of CSF leak, after adult posterior fossa craniotomies versus craniectomies. Secondary outcomes included the rate of postoperative pseudomeningocele formation, CSF leak and pseudomeningocele formation, CSF diversion, revision surgery, and infection. Pooled estimates and relative risks for dichotomous outcomes were calculated using Review Manager 5.4, with corresponding 95% confidence intervals (CIs). Results: A total of 1250 patients (635 craniotomies and 615 craniectomies), from nine studies, were included in the final analysis. Even though rates of CSF leak favored craniotomies, the difference did not reach statistical significance in our pooled analysis (Risk Ratio: 0.71, 95% Confidence Interval: 0.45-1.14, p-value = 0.15, Heterogeneity I-squared = 0%). On the other hand, comparing the rates of pseudomeningocele formation and CSF leak, as a combined outcome, or pseudomeningocele formation only showed a significant difference favoring craniotomies. The quality of evidence in this meta-analysis was graded as having a high risk of bias based on the risk of bias in non-randomized studies - of exposure criteria. Conclusion: Based on evidence with high risk of bias, rates of postoperative CSF leak and pseudomeningocele formation favored posterior fossa craniotomies over craniectomies. Further research with more robust methodology is required to validate these findings.

Beta blockers in traumatic brain injury: a systematic review and meta-analysis.

Background: Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Beta blockers have shown promise in improving mortality and functional outcomes after TBI. The aim of this article is to synthesize the available clinical data on the use of beta blockers in acute TBI. Methods: A systematic search was conducted through MEDLINE, Embase, and Cochrane Central Register of Controlled Trials for studies including one or more outcomes of interest associated with use of beta blockers in TBI. Independent reviewers evaluated the quality of the studies and extracted data on all patients receiving beta blockers during their hospital stay compared with placebo or non-intervention. Pooled estimates, CIs, and risk ratios (RRs) or ORs were calculated for all outcomes. Results: 13 244 patients from 17 studies were eligible for analysis. Pooled analysis demonstrated a significant mortality benefit of overall use of beta blocker (RR 0.8, 95% CI 0.68 to 0.94, I 2=75%). Subgroup analysis of patients with no preinjury use of beta blocker compared with patients on preinjury beta blockers showed no mortality difference (RR 0.99, 95% CI 0.7 to 1.39, I 2=84%). There was no difference in rate of good functional outcome at hospital discharge (OR 0.94, 95% CI 0.56 to 1.58, I 2=65%); however, there was a functional benefit at longer-term follow-up (OR 1.75, 95% CI 1.09 to 2.8, I 2=0%). Cardiopulmonary and infectious complications were more likely in patients who received beta blockers (RR 1.94, 95% CI 1.69 to 2.24, I 2=0%; RR 2.36, 95% CI 1.42 to 3.91, I 2=88%). Overall quality of the evidence was very low. Conclusions: Use of beta blockers is associated with decreased mortality at acute care discharge as well as improved functional outcome at long-term follow-up. Lack of high-quality evidence limits definitive recommendations for use of beta blockers in TBI; therefore, high-quality randomized trials are needed to further elucidate the utility of beta blockers in TBI. PROSPERO registration number: CRD42021279700.

Surgical aspiration versus excision for intraparenchymal abscess: a systematic review and Meta-analysis.

Brain abscesses are associated with considerable morbidity and mortality, requiring timely intervention to achieve favourable outcomes. With the advent of high-resolution computed tomography (CT) imaging, mortality following both aspiration and excision of brain abscesses has improved markedly. As a result, there has been a marked shift in neurosurgical practice with aspiration eclipsing excision as the favoured first-line modality for most abscesses. However, this trend lacks sufficient supporting evidence, and this systematic review and meta-analysis seeks to compare aspiration and excision in the treatment of brain abscess. Twenty-seven studies were included in the systematic review, and seven comparative papers in meta-analysis. Aspiration was the chosen technique for 67.5% of patients. Baseline characteristics from the studies included only in the systematic review demonstrated that abscesses treated by aspiration were typically larger and in a deeper location than those excised. In the meta-analysis, we initially found no significant difference in mortality, re-operation rate, or functional outcome between the two treatment modalities. However, sensitivity analysis revealed that excision results in lower re-operation rate. On average, the included studies were of poor quality with average Methodological Index for Non-Randomized Studies (MINORS) scores of 10.3/16 and 14.43/24 for non-comparative and comparative papers respectively. Our study demonstrates that excision may offer improved re-operation rate as compared to aspiration for those abscesses where there is no prior clinical indication for either modality. However, no differences were found with respect to mortality or functional outcome. Evidence from the literature was deemed low quality, emphasizing the need for further investigation in this field, specifically in the form of large, well-controlled, comparative trials.

Randomized controlled trials in neurosurgery.

Randomized controlled trials (RCTs) have become the standard method of evaluating new interventions (whether medical or surgical), and the best evidence used to inform the development of new practice guidelines. When we review the history of medical versus surgical trials, surgical RCTs usually face more challenges and difficulties when conducted. These challenges can be in blinding, recruiting, funding, and even in certain ethical issues. Moreover, to add to the complexity, the field of neurosurgery has its own unique challenges when it comes to conducting an RCT. This paper aims to provide a comprehensive review of the history of neurosurgical RCTs, focusing on some of the most critical challenges and obstacles that face investigators. The main domains this review will address are: (1) Trial design: equipoise, blinding, sham surgery, expertise-based trials, reporting of outcomes, and pilot trials, (2) trial implementation: funding, recruitment, and retention, and (3) trial analysis: intention-to-treat versus as-treated and learning curve effect.

Pediatric craniocerebral gunshot injuries: A National Trauma Database study.

BACKGROUND: We aimed to determine the outcomes and prognostic factors in pediatric craniocerebral gunshot injury (CGI) patients. Pediatric patients may have significantly different physiology, neuroplasticity, and clinical outcomes in CGI than adults. There is limited literature on this topic, mainly case reports and small case series. METHODS: We queried the National Trauma Data Bank for all pediatric CGI between 2014 and 2017. Patients were identified using International Classification of Diseases, Ninth Revision, codes. Demographic, emergency department, and clinical data were analyzed. Subgroup analysis was attempted for groups with Glasgow Coma Scale (GCS) scores of 9 to 15 and ages 0 to 8 years. RESULTS: In a 3-year period, there were 209 pediatric patients (aged 0-18 years) presenting to American hospitals with signs of life. The overall mortality rate was 53.11%. A linear relationship was demonstrated showing a mortality rate of 79% by initial GCS in GCS score of 3, 56% in GCS scores of 4 to 8, 22% in GCS scores of 9 to 12, and 5% in GCS scores of 13 to 15. The youngest patients, aged 0 to 8 years, had dramatically better initial GCS and subsequently lower mortality rates. Regression analysis showed mortality benefit in the total population for intracranial pressure monitoring (odds ratio, 0.267) and craniotomy (odds ratio, 0.232). CONCLUSION: This study uses the National Trauma Data Bank to quantify the prevalence of pediatric intracranial gunshot wounds, with the goal to determine risk factors for prognosis in this patient population. Significant effects on mortality for invasive interventions including intracranial pressure monitoring and craniotomy for all patients suggest low threshold for use of these procedures if there is any clinical concern. The presence of a 79% mortality rate in patients with GCS score of 3 on presentation suggests that as long as there is not a declared neurologic death, intracranial pressure monitoring and treatment measures including craniotomy should be considered by the consulting clinician. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Pharmacoprophylaxis for Venous Thromboembolism in Spinal Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: Venous thromboembolism (VTE) is a significant contributor to postoperative morbidity and mortality. Prophylactic regimens for VTE involve mechanical prophylaxis and pharmacoprophylaxis. This systematic review and meta-analysis aimed to determine the efficacy and safety of pharmacoprophylaxis in comparison with any nonpharmacoprophylaxis regimen for the prevention of postoperative VTE in patients undergoing spinal surgery. METHODS: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and ICRCTN were searched for comparative studies including both pharmacoprophylaxis and nonpharmacoprophylaxis post spinal surgery. The primary outcome was the incidence of VTE within the postoperative hospitalized period. Secondary outcomes included the incidence of spinal epidural hematoma, significant bleeding events, and other adverse events associated with VTE. The data was pooled using random-effects models of meta-analysis and relative risk (RR) was calculated. RESULTS: Four retrospective and 3 randomized controlled trials representing a total of 8373 patients were included. Overall, there was a significant decrease in postoperative deep venous thrombosis with pharmacoprophylaxis versus nonpharmacoprophylaxis (RR 0.42, 95% confidence interval 0.21-0.86, P = 0.02, I2 = 0%); however, there were no significant differences between the groups in the incidences of VTE (RR 0.31, 95% confidence interval 0.12-0.81, P = 0.02, I2 = 0%). The incidences of spinal epidural hematoma and significant bleeding events were rare and comparable in both groups. CONCLUSIONS: This systematic review and meta-analysis found a potential benefit with pharmacoprophylaxis post spinal surgery in the prevention of deep venous thrombosis. However, there is a need for future randomized controlled trials to investigate the efficacy and safety of pharmacoprophylaxis in spinal surgery across various spinal procedures.

Toward an all-inclusive trauma system in Central South Ontario: development of the Trauma-System Performance Improvement and Knowledge Exchange (T-SPIKE) project.

Background: There is currently no integrated data system to capture the true burden of injury and its management within Ontario's regional trauma networks (RTNs), largely owing to difficulties in identifying these patients across the multiple health care provider records. Our project represents an iterative effort to create the ability to chart the course of care for all injured patients within the Central South RTN. Methods: Through broad stakeholder engagement of major health care provider organizations within the Central South RTN, we obtained research ethics board approval and established data-sharing agreements with multiple agencies. We tested identification of trauma cases from Jan. 1 to Dec. 31, 2017, and methods to link patient records between the various echelons of care to identify barriers to linkage and opportunities for administrative solutions. Results: During 2017, potential trauma cases were identified within ground paramedic services (23 107 records), air medical transport services (196 records), referring hospitals (7194 records) and the lead trauma hospital trauma registry (1134 records). Linkage rates for medical records between services ranged from 49% to 92%. Conclusion: We successfully conceptualized and provided a preliminary demonstration of an initiative to collect, collate and accurately link primary data from acute trauma care providers for certain patients injured within the Central South RTN. Administration-level changes to the capture and management of trauma data represent the greatest opportunity for improvement.

Contexte: On ne dispose actuellement d'aucun système intégré de gestion des données pour évaluer le fardeau réel des traumatismes et de leur gestion dans les réseaux régionaux de traumatologie (RRT) en Ontario, en bonne partie en raison de la difficulté d'identifier les cas parmi la multiplicité des dossiers d'intervenants médicaux. Notre projet représente un effort itératif pour créer la capacité de cartographier le parcours de soin de tous les polytraumatisés du RRT de la région Centre-Sud. Méthodes: Grâce à l'engagement général des intervenants des grandes organisations de santé du RRT de la région Centre-Sud, nous avons obtenu l'approbation d'un comité d'éthique de la recherche et conclu des accords de partage des données avec plusieurs agences. Nous avons testé l'identification des cas de traumatologie du 1er janvier au 31 décembre 2017 et les méthodes de liaison des dossiers de patients entre les divers échelons de soin pour identifier les obstacles à la liaison et leurs solutions administratives possibles. Résultats: Au cours de 2017, les cas de traumatologie potentiels ont été identifiés auprès des services ambulanciers terrestres (23 107 dossiers), des services de transport médical aérien (196 dossiers), des hôpitaux référents (7194 dossiers) et du registre hospitalier principal de traumatologie (1134 dossiers). Les taux de liaison entre les différents services pour les dossiers médicaux variaient de 49 % à 92 %. Conclusion: Nous avons conceptualisé et présenté avec succès la démonstration préliminaire d'un projet visant à recueillir, colliger et relier avec justesse les données primaires des intervenants en traumatologie aiguë pour certains patients blessés du RRT du Centre-Sud. Des changements administratifs centrés sur la saisie et la gestion des données de traumatologie représentent la meilleure voie vers une amélioration.

Frame-based versus frameless stereotactic brain biopsies: A systematic review and meta-analysis.

BACKGROUND: Stereotactic brain biopsy techniques have been a focus of rapid technological innovation. The recent advent of frameless stereotaxy has invited the question of whether it can provide the same diagnostic yield as frame-based techniques, without increasing risk of harm to patients. The goal of this meta-analysis was to compare each of these techniques in terms of yield and safety. METHODS: We independently searched four databases for English studies comparing frameless and frame-based stereotactic brain biopsies. Our primary outcome was biopsy diagnostic yield. Our secondary outcomes included mortality, morbidity (e.g., symptomatic postbiopsy intracranial hemorrhage, asymptomatic postbiopsy intracranial hemorrhage, new postbiopsy neurological deficit, and postbiopsy seizure), and frequency of repeat biopsy. We calculated pooled estimates and relative risks for dichotomous outcomes using Review Manager 5.3, with corresponding 95% confidence intervals. RESULTS: A total of 3256 stereotactic brain biopsies (2050 frame based and 1206 frameless), from 20 studies, were included in our final analysis. The results did not demonstrate any significant difference between the two stereotactic systems in terms of diagnostic yield (risk ratio [RR] 1.00, 95% confidence interval [CI] 0.99-1.02, P = 0.64, I2 = 0%). The only significant difference was the increased frequency of asymptomatic hemorrhages in the frameless group (RR 1.37, 95% CI 1.06-1.75, P = 0.01, I2 = 0%). Application of Grading of Recommendations Assessment, Development, and Evaluation to the results yielded very low quality of all outcomes. CONCLUSION: Based on very low-quality evidence, both frame-based and frameless stereotaxy are safe and effective for biopsy of intracranial tumors. Further study of patient preference and cost comparing analysis is required to identify if either modality should be preferred.

A Review of the Neurosurgical Management of Brain Metastases During Pregnancy.

OBJECTIVE: Patients with pregnancy-associated secondary brain tumors (PASBT) are challenging to manage. Because no guidelines for the management of such patients currently exist, we performed a systematic review of the literature using PRISMA guidelines with a discussion of management from a neurosurgeon's perspective. METHOD: Systematic review of the literature using PRISMA guidelines from 1999 to 2018. RESULTS: We identified 301 studies of which 16 publications (22 patients reporting 25 pregnancies, 20 deliveries, 5 early terminations) were suitable for final analysis. The most frequent primary cancers were breast (8/22, 36.36%), skin (6/22, 27.27%), and lung (5/22, 22.73%). Four patients (18.18%) had neurosurgical procedures during their pregnancies. Five patients (22.73%) received neurosurgical resection after their pregnancies. Nine patients (40.91%) received radiation therapy and seven patients (31.82%) received chemotherapy during pregnancy while seven patients (31.82%) received chemotherapy and radiation after pregnancy. There was 1 fetal death (5%) out of 20 healthy deliveries. Five pregnancies (20%) were terminated in the first trimester due to a need for urgent neurosurgical intervention. CONCLUSION: Management of PASBT remains a challenging issue. Maternal and fetal risks associated with surgical resection and teratogenicity due to adjuvant therapy should be discussed in the context of a multidisciplinary team. Timing of surgery and the use of systemic chemoradiation depends on the gestational age (GA) of the fetus, extent, and control of the mother's primary and metastatic disease. Guidelines need to be established to help neuro-oncology teams safely and effectively manage this group of patients.

Outcomes of civilian pediatric craniocerebral gunshot wounds: A systematic review.

BACKGROUND: Pediatric craniocerebral gunshot injuries (CGIs) occur both in the context of accidental and intentional trauma. The incidence and physiology of pediatric CGIs merit reexamination of prognostic factors and treatment priorities. This study characterizes the current understanding of mortality and prognostic factors in this patient population. METHODS: A systematic search was conducted. Selection criteria included all studies published since 2000, which described civilian isolated CGIs in pediatric patients. Data were analyzed qualitatively and quantitatively to identify factors prognostic for the primary outcome of mortality. Secondary outcomes included functional outcome status, requirement for surgery, and injury complications. Study quality was assessed with the Newcastle-Ottawa Scale. This study was registered with PROSPERO (CRD42019134231). RESULTS: Initial search revealed 349 unique studies. Forty underwent full text screening, and eight studies were included in the final synthesis. The overall mortality rate was 44.8%. Most CGIs occurred in older teenagers. Aggressive surgical treatment was recommended by one author, while remaining studies emphasized clinical judgment. Reported prognostic factors include initial Glasgow Coma Scale, pupil reactivity, involvement of multiple lobes or deep nuclei, and bihemispheric injuries. Reported complications from CGIs included seizure, meningitis, abscess, cerebrospinal fluid leak, bullet migration, focal neurological deficits, endocrine abnormalities, cognitive deficits, and neuropsychological deficits. The Glasgow Outcome Scale was the predominant measure of function and demonstrated a moderate recovery in 17.4% and a good recovery in 27.3% of patients. CONCLUSION: This systematic review analyzed the existing evidence for prognostic factors in the context of pediatric CGIs. Significant long-term clinical improvement is possible with interventions including urgent surgical therapy. Fixed bilateral pupils and low initial Glasgow Coma Scale correlate with mortality but do not predict all patient outcomes. Patients younger than 15 years are underreported and may have differences in outcome. The literature on pediatric CGIs is limited and requires further characterization. LEVEL OF EVIDENCE: Systematic Review, level IV.

Atraumatic versus traumatic lumbar puncture needles: a systematic review and meta-analysis protocol.

INTRODUCTION: Lumbar puncture is one of the oldest and most commonly performed procedures in medicine, used to diagnose and treat disease. Headache following lumbar puncture remains a frequent complication, causing significant patient discomfort and often requiring narcotic analgesia or invasive therapy. Needle tip design has been proposed to affect the incidence of headache postlumbar puncture, with pencil-point 'atraumatic' needles thought to reduce its incidence in comparison to bevelled 'traumatic' needles. Despite this, the use of atraumatic needles and knowledge of their existence remains significantly limited among clinicians. This study will systematically review the evidence on atraumatic lumbar puncture needles and compare them with traumatic needles across a variety of clinical outcomes. METHODS AND ANALYSES: We will include published randomised controlled trials (RCTs), observational studies and abstracts, with no publication type or language restrictions. Search strategies will be designed to peruse the MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CINAHL, WHO Clinical Trials Database and Cochrane Library databases. We will also implement strategies to search the grey literature. 3 reviewers will thoroughly and independently examine the search results, complete data abstraction and conduct quality assessment. Included RCTs will be assessed using the Cochrane risk of bias assessment tool and eligible observational studies will be examined using the Newcastle-Ottawa Scale. We will examine the outcomes of: headache and its type, intensity, duration and treatment; backache; success rate; hearing disturbance and nerve root irritation. The primary outcome will be the incidence of postdural puncture headache. We will calculate pooled estimates, relative risks for dichotomous outcomes and weighted mean differences for continuous outcomes, with corresponding 95% CIs. Statistical heterogeneity will be measured using Cochran's Q test and quantified using the I2 statistic. We will also conduct prespecified subgroup and sensitivity analyses to examine if covariates exist and to explore potential heterogeneity. ETHICS AND DISSEMINATION: Research ethics board approval is not required for this study as it draws from published data and raises no concerns related to patient privacy. This review will provide a comprehensive assessment of the evidence on atraumatic needles for lumbar puncture and is directed to a wide audience. Results from the review will be disseminated extensively through conferences and submitted to a peer-reviewed journal for publication. TRIAL REGISTRATION NUMBER: CRD42016047546.

Benchmarking trauma center performance in traumatic brain injury: the limitations of mortality outcomes.

BACKGROUND: Trauma centers (TCs) generally use mortality to gauge performance. However, differences in mortality outcomes might reflect different approaches or philosophies toward end-of-life care. We postulate that discharge home (DH) as a proxy for functional outcome may be a more useful measure of quality and may have significant implications on the assessment of TC performance and external benchmarking efforts. METHODS: Data were derived from the National Trauma Data Bank (2007-2009). We included patients (18 years or older) with isolated, severe blunt head injuries who were admitted to Level I and Level II TCs. Observed-to-expected (O/E) mortality ratios were calculated and used to rank TC performance by mortality and then DH. Concordance between performance measures was calculated using a weighted kappa statistic. RESULTS: In total, 19,705 patients in 240 TCs were identified. Crude mortality ranged from 4% to 60%, whereas rates of DH ranged from 3% to 66%. When O/E ratios for mortality were evaluated, five centers were identified as high performers. Of these five centers, only two were also high performers for DH. The concordance of outlier status and correlation across O/E ratios between mortality and DH high performers was 0.16 (poor). CONCLUSION: Centers that are characterized as high performers when evaluating mortality are not high performers for functional outcome as evaluated by DH. DH may provide an alternative way of assessing quality of care delivered to patients with traumatic brain injury. LEVEL OF EVIDENCE: Care management study, level III.

A contemporary analysis of the management of the mangled lower extremity.

BACKGROUND: The management of a mangled lower extremity is complex and requires consideration of a patient's injury pattern, medical history, social context, and preference. The Lower Extremity Assessment Project provides the highest level of evidence guiding management; however, the Lower Extremity Assessment Project cohort was recruited 15 years ago and was restricted to Level I trauma centers. Furthermore, as our ability to salvage limbs has improved, the decision to amputate in the early period following injury remains particularly challenging. Given these considerations, our primary objective was to characterize the contemporary management of the mangled lower extremity across a range of trauma centers and identify which patient and injury characteristics are associated with early amputation. METHODS: We used a retrospective cohort design and included adults in the National Trauma Databank (2007-2009) with a mangled lower extremity treated at Level I or II trauma centers. A mangle injury was defined as (1) a severe crush injury or (2) the combination of a severe fracture with selected severe injuries from at least two of three categories as follows: soft tissue, artery, or nerve. Logistic regression was used to evaluate the association of patient and injury characteristics with our primary outcome: amputation performed before the end of the first full calendar day following emergency department arrival (early amputation). RESULTS: A total of 1,354 patients were identified from 222 centers; 278 (21%) underwent amputation during their hospital course, with 124 (9%) undergoing early amputation. On multivariable analysis, only injury characteristic was associated with early amputation. The presence of severe head injury (Abbreviated Injury Scale [AIS] score ≥ 3), shock in the emergency department (systolic blood pressure < 90 mm Hg), limb injury type, and higher-energy mechanism were independently associated with early amputation. CONCLUSION: Nearly half of all in-hospital amputations for mangled lower extremities are performed early. The decision to amputate early may not be guided by age, comorbidity level, or insurance status but rather by systemic and local injury characteristics. LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic/epidemiologic study, level IV.

Institutional and provider factors impeding access to trauma center care: an analysis of transfer practices in a regional trauma system.

BACKGROUND: More than a third of patients with severe injury who receive initial care at nontrauma centers (NTCs) are not transferred to trauma center care. In those who are transferred, significant delays have been described. The availability of specialists, imaging modalities, or critical care resources might significantly affect transfer practices. METHODS: We undertook a population-based retrospective cohort study of adult patients with severe injury who were transported from the scene to an NTC. NTCs were characterized based on the availability of general and orthopedic surgeons, computed tomographic scanners, intensive care units, and emergency department staffing. NTCs that had all of the resources were characterized as resource rich, while those with none were characterized as resource limited. We evaluated the relationships between NTC resources and the likelihood and timeliness of interfacility transfer through the use of hierarchical regression modeling. RESULTS: We identified 15,906 patients with severe injury across 192 NTCs (22% were resource limited, 57% were resource intermediate, and 21% were resource rich). Patients at resource rich centers, as compared with those at resource limited centers, were less likely to be transferred (27% vs. 50%, p < 0.001). This association persisted after adjustment for confounders (odds ratio, 0.66; 95% confidence interval, 0.47-0.92). Among patients who were transferred, median emergency department length of stay (ED-LOS) was 3.5 hours (interquartile range, 1.7-4.6 hours). However, ED-LOS varied significantly because resource rich centers had a greater proportion of patients experiencing prolonged ED-LOS when compared with resource limited centers (31% vs. 15%, p < 0.001). This association also persisted on multivariable analysis (odds ratio, 2.02; 95% confidence interval, 1.19-3.43). CONCLUSION: Severely injured patients who received initial care in resource rich NTCs were less likely to be transferred to a trauma center compared with resource limited NTCs. Significant delays in the transfer process were identified. However, patients transferred from resource rich centers were more likely to experience prolonged ED-LOS compared with resource limited NTCs. LEVEL OF EVIDENCE: Epidemiologic study, level II.

The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis.

BACKGROUND: By ensuring timely access to trauma center (TC) care, well-organized trauma systems have the potential to significantly reduce injury-related mortality. However, undertriage continues to be a significant problem in many regional trauma systems. Taking a novel, population-based approach, we estimated the potential detrimental impact of undertriage to a non-TC (NTC) within a regional system. METHODS: We performed a population-based, retrospective cohort study of TC effectiveness in a region with urban, suburban, and rural areas. Data were derived from administrative databases capturing all emergency department deaths and admissions in the region. Adult motor vehicle collision occupants presenting to any emergency department in the study region were included (2002-2010). Data were limited to patients with severe injury. The exposure of interest was initial triage destination (TC or NTC), regardless of later transfer to TC. Mortality was compared across groups, using an instrumental variable analysis to adjust for confounding. RESULTS: Among 6,341 motor vehicle collision occupants, 45% (n = 2,857) were triaged from the scene of injury to a TC. Among patients transported from the scene to a NTC, 57% (n = 2,003) were transferred to a TC within 24 hours of initial evaluation. Compared with patients triaged to a NTC, adjusted mortality was lower among patients triaged directly to a TC, both at 24 hours (odds ratio: 0.58, 95% confidence interval: 0.41-0.84) and at 48 hours (odds ratio: 0.68, 95% confidence interval: 0.48-0.96). A trend toward reduced mortality with TC triage was also observed at 7 and 30 days. CONCLUSIONS: Our data are population-based evidence of the early benefits of direct triage to TC. Although many surviving patients are later transferred to a TC, initial triage to a NTC is associated with at least a 30% increase in mortality in the first 48 hours after injury. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Gender-associated differences in access to trauma center care: A population-based analysis.

BACKGROUND: Disparities in access to services across genders have been reported in many healthcare settings. The extent to which this occurs in the case of emergency surgical care is unknown. We set out to evaluate whether gender is a determinant of access to trauma center care, particularly in the setting where trauma triage guidelines are strong facilitators to ensure that access is determined by physiologic status and injury characteristics. METHODS: Population-based retrospective cohort analysis of severely injured (Injury Severity Score >15) adults surviving to reach hospital. Differential in access to trauma center care was evaluated for females compared with males. Secondary analyses evaluated gender-based differences in direct transport from the scene and transfer from nontrauma centers. The adjusted odd of trauma center care was determined using logistic regression models. Separate models were used to stratify patients based on age, mechanism, and injury severity. RESULTS: We identified 26,861 severely injured patients; 35% were women. A smaller proportion of females received trauma center care compared with males (49% vs 62%; P < .0001), an association that persisted after adjustment for confounders (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.79-0.96). Emergency medical service personnel were less likely to transport females from the field to a trauma center compared with males (OR, 0.88; 95% CI, 0.81-0.97). Similarly, physicians were less likely to transfer females to trauma centers compared with males (OR, 0.85; 95% CI, 0.73-0.99). CONCLUSION: Severely injured women were less likely to be directed to a trauma center across 2 types of providers. The reasons for this differential in access might be related to perceived difference in injury severity, likelihood of benefiting from trauma center care, or subconscious gender bias.