Proteomics of Coagulopathy Following Injury Reveals Limitations of Using Laboratory Assessment to Define Trauma-Induced Coagulopathy to Predict Massive Transfusion.

Objective: Trauma-induced coagulopathy (TIC) is provoked by multiple mechanisms and is perceived to be one driver of massive transfusions (MT). Single laboratory values using prothrombin time (INR) or thrombelastography (TEG) are used to clinically define this complex process. We used a proteomics approach to test whether current definitions of TIC (INR, TEG, or clinical judgement) are sufficient to capture the majority of protein changes associated with MT. Methods: Eight level-I trauma centers contributed blood samples from patients available early after injury. TIC was defined as INR >1.5 (INR-TIC), TEG maximum amplitude <50mm (TEG-TIC), or clinical judgement (Clin-TIC) by the trauma surgeon. MT was defined as > 10 units of red blood cells in 24 hours or > 4 units RBC/hour during the first 4 hr. SomaLogic proteomic analysis of 1,305 proteins was performed. Pathways associated with proteins dysregulated in patients with each TIC definition and MT were identified. Results: Patients (n=211) had a mean injury severity score of 24, with a MT and mortality rate of 22% and 12%, respectively. We identified 578 SOMAscan analytes dysregulated among MT patients, of which INR-TIC, TEG-TIC, and Clin-TIC patients showed dysregulation only in 25%, 3%, and 4% of these, respectively. TIC definitions jointly failed to show changes in 73% of the protein levels associated with MT, and failed to identify 26% of patients that received a massive transfusion. INR-TIC and TEG-TIC patients showed dysregulation of proteins significantly associated with complement activity. Proteins dysregulated in Clin-TIC or massive transfusion patients were not significantly associated with any pathway. Conclusion: These data indicate there are unexplored opportunities to identify patients at risk for massive bleeding. Only a small subset of proteins that are dysregulated in patients receiving MT are statistically significantly dysregulated among patients whose TIC is defined based solely on laboratory measurements or clinical assessment.

Evaluating the Cost-effectiveness of Prehospital Plasma Transfusion in Unstable Trauma Patients: A Secondary Analysis of the PAMPer Trial.

Importance: Prehospital plasma transfusion is lifesaving for trauma patients in hemorrhagic shock but is not commonly used owing to cost and feasibility concerns. Objective: To evaluate the cost-effectiveness of prehospital thawed plasma transfusion in trauma patients with hemorrhagic shock during air medical transport. Design, Setting, and Participants: A decision tree and Markov model were created to compare standard care and prehospital thawed plasma transfusion using published and unpublished patient-level data from the Prehospital Plasma in Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock (PAMPer) trial conducted from May 2014 to October 2017, health care and trauma-specific databases, and the published literature. Prehospital transfusion, short-term inpatient care, and lifetime health care costs and quality of life outcomes were included. One-way, 2-way, and Monte Carlo probabilistic sensitivity analyses were performed across clinically plausible ranges. Data were analyzed in December 2019. Main Outcomes and Measures: Relative costs and health-related quality of life were evaluated by an incremental cost-effectiveness ratio at a standard willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). Results: The trial included 501 patients in the modified intention-to-treat cohort. Median (interquartile range) age for patients in the thawed plasma and standard care cohorts were 44 (31-59) and 46 (28-60) years, respectively. Overall, 364 patients (72.7%) were male. Thawed plasma transfusion was cost-effective with an incremental cost-effectiveness ratio of $50 467.44 per QALY compared with standard care. The preference for thawed plasma was robust across all 1- and 2-way sensitivity analyses. When considering only patients injured by a blunt mechanism, the incremental cost-effectiveness ratio decreased to $37 735.19 per QALY. Thawed plasma was preferred in 8140 of 10 000 iterations (81.4%) on probabilistic sensitivity analysis. A detailed analysis of incremental costs between strategies revealed most were attributable to the in-hospital and postdischarge lifetime care of critically ill patients surviving severe trauma. Conclusions and Relevance: In this study, prehospital thawed plasma transfusion during air medical transport for trauma patients in hemorrhagic shock was lifesaving and cost-effective compared with standard care and should become commonplace.

Geospatial assessment of helicopter emergency medical service overtriage.

BACKGROUND: Despite evidence of benefit after injury, helicopter emergency medical services (HEMS) overtriage remains high. Scene and transfer overtriage are distinct processes. Our objectives were to identify geographic variation in overtriage and patient-level predictors, and determine if overtriage impacts population-level outcomes. METHODS: Patients 16 years or older undergoing scene or interfacility HEMS in the Pennsylvania Trauma Outcomes Study were included. Overtriage was defined as discharge within 24 hours of arrival. Patients were mapped to zip code, and rates of overtriage were calculated. Hot spot analysis identified regions of high and low overtriage. Mixed-effects logistic regression determined patient predictors of overtriage. High and low overtriage regions were compared for population-level injury fatality rates. Analyses were performed for scene and transfer patients separately. RESULTS: A total of 85,572 patients were included (37.4% transfers). Overtriage was 5.5% among scene and 11.8% among transfer HEMS (p < 0.01). Hot spot analysis demonstrated geographic variation in high and low overtriage for scene and transfer patients. For scene patients, overtriage was associated with distance (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06 per 10 miles; p = 0.04), neck injury (OR, 1.27; 95% CI, 1.01-1.60; p = 0.04), and single-system injury (OR, 1.37; 95% CI, 1.15-1.64; p < 0.01). For transfer patients, overtriage was associated with rurality (OR, 1.64; 95% CI, 1.22-2.21; p < 0.01), facial injury (OR, 1.22; 95% CI, 1.03-1.44; p = 0.02), and single-system injury (OR, 1.35; 95% CI, 1.18-2.19; p < 0.01). For scene patients, high overtriage was associated with higher injury fatality rate (coefficient, 1.72; 95% CI, 1.68-1.76; p < 0.01); low overtriage was associated with lower injury fatality rate (coefficient, -0.73; 95% CI, -0.78 to -0.68; p < 0.01). For transfer patients, high overtriage was not associated with injury fatality rate (p = 0.53); low overtriage was associated with lower injury fatality rate (coefficient, -2.87; 95% CI, -4.59 to -1.16; p < 0.01). CONCLUSION: Geographic overtriage rates vary significantly for scene and transfer HEMS, and are associated with population-level outcomes. These findings can help guide targeted performance improvement initiatives to reduce HEMS overtriage. LEVEL OF EVIDENCE: Therapeutic, level IV.

Disparities in rural versus urban field triage: Risk and mitigating factors for undertriage.

BACKGROUND: There are well-known disparities for patients injured in rural setting versus urban setting. Many cite access to care; however, the mechanisms are not defined. One potential factor is differences in field triage. Our objective was to evaluate differences in prehospital undertriage (UT) in rural setting versus urban settings. METHODS: Adult patients in the Pennsylvania Trauma Outcomes Study (PTOS) registry 2000 to 2017 were included. Rural/urban setting was defined by county according to the Pennsylvania Trauma Systems Foundation. Rural/urban classification was performed for patients and centers. Undertriage was defined as patients meeting physiologic or anatomic triage criteria from the National Field Triage Guidelines who were not initially transported to a Level I or Level II trauma center. Logistic regression determined the association between UT and rural/urban setting, adjusting for transport distance and prehospital time. Models were expanded to evaluate the effect of individual triage criteria, trauma center setting, and transport mode on UT. RESULTS: There were 453,112 patients included (26% rural). Undertriage was higher in rural patients (8.6% vs. 3.4%, p < 0.01). Rural setting was associated with UT after adjusting for distance and prehospital time (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.82-6.78; p < 0.01). Different triage criteria were associated with UT in rural/urban settings. Rural setting was associated with UT for patients transferred to an urban center (OR, 3.32; 95% CI, 1.75-6.25; p < 0.01), but not a rural center (OR, 0.68; 95% CI, 0.08-5.53; p = 0.72). Rural setting was associated with UT for ground (OR, 5.01; 95% CI, 2.65-9.46; p < 0.01) but not air transport (OR, 1.18; 95% CI, 0.54-2.55; p = 0.68). CONCLUSION: Undertriage is more common in rural settings. Specific triage criteria are associated with UT in rural settings. Lack of a rural trauma center requiring transfer to an urban center is a risk factor for UT of rural patients. Air medical transport mitigated the risk of UT in rural patients. Provider and system interventions may help reduce UT in rural settings. LEVEL OF EVIDENCE: Care Management, Level IV.

Effects of hospital-acquired pneumonia on long-term recovery and hospital resource utilization following moderate to severe traumatic brain injury.

BACKGROUND: Individuals with traumatic brain injury (TBI) have extended inpatient hospital stays that include prolonged mechanical ventilation, increasing risk for infections, including pneumonia. Studies show the negative short-term effects of hospital-acquired pneumonia (HAP) on hospital-based outcomes; however, little is known of its long-term effects. METHODS: A prospective cohort study was conducted. National Trauma Databank and Traumatic Brain Injury Model Systems were merged to derive a cohort of 3,717 adults with moderate-to-severe TBI. Exposure data were gathered from the National Trauma Databank, and outcomes were gathered from the Traumatic Brain Injury Model Systems. The primary outcome was the Glasgow Outcome Scale-Extended (GOS-E), which was collected at 1, 2, and 5 years postinjury. The GOS-E was categorized as favorable (>5) or unfavorable (≤5) outcomes. A generalized estimating equation model was fitted estimating the effects of HAP on GOS-E over the first 5 years post-TBI, adjusting for age, race, ventilation status, brain injury severity, injury severity score, thoracic Abbreviated Injury Scale score of 3 or greater, mechanism of injury, intraventricular hemorrhage, and subarachnoid hemorrhage. RESULTS: Individuals with HAP had a 34% (odds ratio, 1.34; 95% confidence interval, 1.15-1.56) increased odds for unfavorable GOS-E over the first 5 years post-TBI compared with individuals without HAP, after adjustment for covariates. There was a significant interaction between HAP and follow-up, such that the effect of HAP on GOS-E declined over time. Sensitivity analyses that weighted for nonresponse bias and adjusted for differences across trauma facilities did not appreciably change the results. Individuals with HAP spent 10.1 days longer in acute care and 4.8 days longer in inpatient rehabilitation and had less efficient functional improvement during inpatient rehabilitation. CONCLUSION: Individuals with HAP during acute hospitalization have worse long-term prognosis and greater hospital resource utilization. Preventing HAP may be cost-effective and improve long-term recovery for individuals with TBI. Future studies should compare the effectiveness of different prophylaxis methods to prevent HAP. LEVEL OF EVIDENCE: Prospective cohort study, level III.

Defining geographic emergency medical services coverage in trauma systems.

BACKGROUND: Geographic distribution of trauma system resources including trauma centers and helicopter bases correlate with outcomes. However, ground emergency medical services (EMS) coverage is dynamic and more difficult to quantify. Our objective was to evaluate measures that describe ground EMS coverage in trauma systems and correlate with outcome. METHODS: Trauma system resources in Pennsylvania were mapped. Primary outcome was county age-adjusted transportation injury fatality rate. Measures of county EMS coverage included average distance to the nearest trauma center, number of basic life support and advanced life support units/100 square miles, distance differential between the nearest trauma center and nearest helicopter base, and nearest neighbor ratio (dispersed or clustered geographic pattern of agencies). Spatial-lag regression determined association between fatality rates and these measures, adjusted for prehospital time, Injury Severity Score, and socioeconomic factors. Relative importance of these measures was determined by assessing the loss in R value from the full model by removing each measure. A Geographic Emergency Medical Services Index (GEMSI) was created based on these measures for each county. RESULTS: Median fatality rate was higher in counties with fewer trauma system resources. Decreasing distance to nearest trauma center, increasing advanced life support units/100 square miles, greater distance reduction due to helicopter bases, and dispersed geographic pattern of county EMS agencies were associated with lower fatality rates. The GEMSI ranged from -6.6 to 16.4 and accounted for 49% of variation in fatality rates. Adding an EMS agency to a single county that produced a dispersed pattern of EMS coverage reduced predicted fatality rate by 6%, while moving a helicopter base into the same county reduced predicted fatality rate by 22%. CONCLUSION: The GEMSI uses several measures of ground EMS coverage and correlates with outcome. This tool may be used to describe and compare ground EMS coverage across trauma system geographies, as well as help optimize the geographic distribution of trauma system resources. LEVEL OF EVIDENCE: Ecological study, level IV.

Implementation of a prehospital air medical thawed plasma program: Is it even feasible?

BACKGROUND: The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a 30-day survival benefit among hypotensive trauma patients treated with prehospital plasma during air medical transport. We characterized resources, costs and feasibility of air medical prehospital plasma program implementation. METHODS: We performed a secondary analysis using data derived from the recent PAMPer trial. Intervention patients received thawed plasma (5-day shelf life). Unused plasma units were recycled back to blood bank affiliates, when possible. Distribution method and capability of recycling varied across sites. We determined the status of plasma units deployed, utilized, wasted, and returned. We inventoried thawed plasma use and annualized costs for distribution and recovery. RESULTS: The PAMPer trial screened 7,275 patients and 5,103 plasma units were deployed across 22 air medical bases during a 42-month period. Only 368 (7.2%) units of this total thawed plasma pool were provided to plasma randomized PAMPer patients. Of the total plasma pool, 3,716 (72.8%) units of plasma were returned to the blood bank with the potential for transfusion prior to expiration and 1,019 (20.0%) thawed plasma units were deemed wasted for this analysis. The estimated average annual cost of implementation of a thawed plasma program per air medical base at an average courier distance would be between US $24,343 and US $30,077, depending on the ability to recycle plasma and distance of courier delivery required. CONCLUSION: A prehospital plasma program utilizing thawed plasma is resource intensive. Plasma waste can be minimized depending on trauma center and blood bank specific logistics. Implementation of a thawed plasma program can occur with financial cost. Products with a longer shelf life, such as liquid plasma or freeze-dried plasma, may provide a more cost-effective prehospital product relative to thawed plasma. LEVEL OF EVIDENCE: Therapeutic, level III.

Surgical rescue: The next pillar of acute care surgery.

BACKGROUND: The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of "surgical rescue" in the practice of ACS. METHODS: A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index. RESULTS: Of 2,410 ACS patients, 320 (13%) required "surgical rescue": most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients ("local"), whereas 38% were referred from another surgical service ("institutional") and 26% referred from another institution ("regional"). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between "local" and "institutional" patients, but hospital length of stay and discharge to home were significantly worse in "institutional" referrals. CONCLUSION: We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the "surgical rescue" of surgical and procedural complications. LEVEL OF EVIDENCE: Epidemiological study, level III; therapeutic/care management study, level IV.

Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level.

BACKGROUND: Trauma activation level is determined by prehospital criteria. The American College of Surgeons (ACS) recommends trauma activation criteria; however, their accuracy may be limited. Prehospital lactate has shown promise in predicting trauma center resource requirements. Our objective was to investigate the added value of incorporating prehospital lactate in an algorithm to designate trauma activation level. METHODS: Air medical trauma patients undergoing prehospital lactate measurement were included. Algorithms using ACS activation criteria (ACS) and ACS activation criteria plus prehospital lactate (ACS+LAC) to designate trauma activation level were compared. Test characteristics and net reclassification improvement (NRI), which evaluates reclassification of patients among risk categories with additional predictive variables, were calculated. Algorithms were compared to predict trauma center need defined as more than 1 unit of blood in the emergency department; spinal cord injury; advanced airway; thoracotomy or pericardiocentesis; ICP monitoring; emergent operative or interventional radiology procedure; or death. RESULTS: There were 6,347 patients included. Twenty-eight percent had trauma center need. The ACS+LAC algorithm upgraded 256 patients and downgraded 548 patients compared to the ACS algorithm. The ACS+LAC algorithm versus ACS algorithm had an NRI of 0.058 (95% confidence interval [CI], 0.044-0.071; p < 0.01), with an event NRI of -0.5% and nonevent NRI of 6.2%. When weighted to favor changes in undertriage, the ACS+LAC still had a favorable overall reclassification (weighted NRI, 0.041; 95% CI, 0.028-0.054; p = 0.01). The ACS+LAC algorithm increased positive predictive value, negative predictive value, and accuracy. Over-triage was reduced 7.2%, while undertriage only increased 0.7%. The area under the curve was significantly higher for the ACS+LAC algorithm (0.79 vs. 0.76; p < 0.01). CONCLUSIONS: The ACS+LAC algorithm reclassified patients to more appropriate levels of trauma activation compared to the ACS algorithm. This overall benefit is achieved by significant reduction in overtriage relative to very small increase in undertriage. In the context of trauma team activation, this trade-off may be acceptable, especially in the current health care environment. LEVEL OF EVIDENCE: Therapeutic/care management study, level III; prognostic/epidemiologic study, level III.

Temporal trends of postinjury multiple-organ failure: still resource intensive, morbid, and lethal.

BACKGROUND: While the incidence of postinjury multiple-organ failure (MOF) has declined during the past decade, temporal trends of its morbidity, mortality, presentation patterns, and health care resources use have been inconsistent. The purpose of this study was to describe the evolving epidemiology of postinjury MOF from 2003 to 2010 in multiple trauma centers sharing standard treatment protocols. METHODS: "Inflammation and Host Response to Injury Collaborative Program" institutions that enrolled more than 20 eligible patients per biennial during the 2003 to 2010 study period were included. The patients were aged 16 years to 90 years, sustained blunt torso trauma with hemorrhagic shock (systolic blood pressure < 90 mm Hg, base deficit ≥ 6 mEq/L, blood transfusion within the first 12 hours), but without severe head injury (motor Glasgow Coma Scale [GCS] score < 4). MOF temporal trends (Denver MOF score > 3) were adjusted for admission risk factors (age, sex, body max index, Injury Severity Score [ISS], systolic blood pressure, and base deficit) using survival analysis. RESULTS: A total of 1,643 patients from four institutions were evaluated. MOF incidence decreased over time (from 17% in 2003-2004 to 9.8% in 2009-2010). MOF-related death rate (33% in 2003-2004 to 36% in 2009-2010), intensive care unit stay, and mechanical ventilation duration did not change over the study period. Adjustment for admission risk factors confirmed the crude trends. MOF patients required much longer ventilation and intensive care unit stay, compared with non-MOF patients. Most of the MOF-related deaths occurred within 2 days of the MOF diagnosis. Lung and cardiac dysfunctions became less frequent (57.6% to 50.8%, 20.9% to 12.5%, respectively), but kidney and liver failure rates did not change (10.1% to 12.5%, 15.2% to 14.1%). CONCLUSION: Postinjury MOF remains a resource-intensive, morbid, and lethal condition. Lung injury is an enduring challenge and should be a research priority. The lack of outcome improvements suggests that reversing MOF is difficult and prevention is still the best strategy. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Radiographic assessment of ground-level falls in elderly patients: Is the "PAN-SCAN" overdoing it?

INTRODUCTION: Routine, whole-body computed tomography imaging (PAN-SCAN) has been shown to identify unexpected injuries and alter the management of patients presenting with blunt trauma. We sought to characterize the changes in practice over time and the utility of PAN-SCAN imaging in elderly patients who fall and require admission to a trauma center. METHODS: We performed a retrospective analysis by using data derived from a Pennsylvania state-wide trauma registry (2007-2010). All hemodynamically stable patients (>65 years) who had a ground-level fall and were admitted for >24 hours were selected. Patients who underwent a combination of all three scans within 2 hours of arrival were considered to have underwent PAN-SCAN imaging. Clinical outcomes were compared across PAN-SCAN patients relative to less diagnostic imaging. Regression analysis was used to determine whether PAN-SCAN imaging was an independent determinate of mortality and resource use. RESULTS: Over the period of study, 13,043 patients met inclusion criteria. The annual rate of PAN-SCAN imaging after ground-level falls increased over time. After we controlled for important confounders, PAN-SCAN imaging was not associated with mortality (odds ratio 0.97, P = .74, 95% confidence interval 0.80-1.18). Despite greater injury severity, PAN-SCAN imaging was independently associated with significantly lesser intensive care unit requirements, step-down days, and a lesser overall duration of stay. CONCLUSION: PAN-SCAN imaging has become more common over time in elderly patients having a ground-level fall. Although PAN-SCAN imaging during the initial trauma evaluation was not associated with an independent decrease in the risk of mortality, it was independently associated with lesser hospital resource use. These data suggest that whole-body computed tomography imaging may benefit trauma center resource use for patients with ground-level falls.

Radiographic assessment of splenic injury without contrast: is contrast truly needed?

INTRODUCTION: Computed tomography (CT) has become an essential tool in the assessment of the stable trauma patient. Intravenous (i.v.) contrast is commonly relied upon to provide superior image quality, particularly for solid-organ injury. However, a substantial proportion of injured patients have contraindications to i.v. contrast. Little information exists concerning the repercussions of CT imaging without i.v. contrast, specifically for splenic injury. METHODS: We performed a retrospective analysis using data from our trauma registry and chart review as part of a quality improvement project at our institution. All patients with splenic injury, during a 3-year period (2008-2010), where a CT of the abdomen without i.v. contrast (DRY) early during their admission were selected. All splenic injuries had to have been verified with abdominal CT imaging with i.v. contrast (CONTRAST) or via intraoperative findings. DRY images were independently read by a single, blinded, radiologist and assessed for parenchymal injury or "suspicious" splenic injury findings and compared with CONTRAST imaging results or intraoperative findings. RESULTS: During the time period of the study, 319 patients had documented splenic injury with 44 (14%) patients undergoing DRY imaging, which was also verified by CONTRAST imaging or operative findings. Splenic parenchymal injury was only visualized in 38% of patients DRY patients. "Suspicious" splenic injury radiographic findings were common. When these less-specific findings for splenic injury were incorporated in the radiographic assessment, DRY imaging had more than 93% sensitivity for detecting splenic injury. CONCLUSION: DRY imaging is increasingly being performed after injury and has a low sensitivity in detecting splenic parenchymal injury. However, less-specific radiographic findings suspicious for splenic injury in combination provide high sensitivity for the detection of splenic injury. These results suggest CONTRAST imaging is preferred to detect splenic injury; however, in those patients who have contraindications to i.v. contrast, DRY imagining may be able to select those who require close monitoring or intervention.

Racial disparities and sex-based outcomes differences after severe injury.

BACKGROUND: Controversy exists about the mechanisms responsible for sex-based outcomes differences post-injury. X-chromosome-linked immune response pathway polymorphisms represent a potential mechanism resulting in sex-based outcomes differences post-injury. The prevalence of these variants is known to differ across race. We sought to characterize racial differences and the strength of any sex-based dimorphism post-injury. STUDY DESIGN: A retrospective analysis was performed using data derived from the National Trauma Data Bank 7.1 (2002-2006). Blunt-injured adult (older than 15 years) patients, surviving >24 hours and with an Injury Severity Score >16 were analyzed (n = 244,371). Patients were stratified by race (Caucasian, black, Hispanic, Asian) and multivariable regression analysis was used to characterize the risk of mortality and the strength of protection associated with sex (female vs male). RESULTS: When stratified by race, multivariable models demonstrated Caucasian females had an 8.5% lower adjusted risk of mortality (odds ratio [OR] = 0.91; 95% CI, 0.88-0.95; p < 0.001) relative to Caucasian males, with no significant association found for Hispanics or blacks. An exaggerated survival benefit was afforded to Asian females relative to Asian males, having a >40% lower adjusted risk of mortality (OR = 0.59; 95% CI, 0.44-78; p < 0.001). Asian males had a >75% higher adjusted risk of mortality relative to non-Asian males (OR = 1.77; 95% CI, 1.5-2.0; p < 0.001), and no significant difference in the mortality risk was found for Asian females relative to non-Asian females. CONCLUSIONS: These results suggest that Asian race is associated with sex-based outcomes differences that are exaggerated, resulting from worse outcomes for Asian males. These racial disparities suggest a negative male X-chromosome-linked effect as the mechanism responsible for these sex-based outcomes differences.

Assessment of platelet transfusion for reversal of aspirin after traumatic brain injury.

BACKGROUND: Platelet transfusion is utilized increasingly for traumatic brain injury (TBI) for the reversal of aspirin (ASA) therapy. Assessment of platelet inhibition and reversal by platelet transfusion after TBI has not been adequately characterized. METHODS: A retrospective cohort analysis of TBI patients at a level I trauma center (January 2008-December 2009) was performed. The Aspirin Response Test (ART; VerifyNow) was used to assess platelet inhibition in TBI patients and guide platelet transfusion in patients with ASA-induced suppression. A follow-up ART was obtained after platelet administration. Primary endpoints were progression of intracranial hemorrhage on computed tomography, need for craniotomy, and mortality. RESULTS: We analyzed 84 patients (median age, 78 [interquartile range, 64-86)]; 54% male). ASA use was documented in 36 (42%) patients. Initial ART indicated platelet dysfunction in 54 (64%) patients, including 42% of patients without a documented history of ASA use. Of the patients with a documented history of ASA, 2.4% had a normal ART. Of those with an initial ART of <550 ASA response units, 45 received platelets. Repeat ART demonstrated reversal of inhibition in 29 patients (64.4%). Initial responders to transfusion received a greater volume of platelets, suggesting a dose-response relationship. Logistic regression revealed a trend toward higher mortality in nonresponders to transfusion (P = .09). Receiver operating characteristic curve analysis revealed that ART results increased prediction of poor outcome compared with ASA history alone (area under the curve = 0.760 and 0.775, respectively). CONCLUSION: The ART should be used to better target and guide platelet transfusions in TBI patients with known or suspected ASA use history. Patients with occult platelet dysfunction can be identified, unnecessary platelet transfusions avoided, and the adequate volume of platelets administered to correct drug-induced dysfunction. A dose-response relationship between quantity of platelets transfused and reversal of ASA inhibition was observed.

The implications of alcohol intoxication and the Uniform Policy Provision Law on trauma centers; a national trauma data bank analysis of minimally injured patients.

BACKGROUND: Alcohol intoxication may confound the initial assessment of trauma patients, resulting in increased use of diagnostic and therapeutic procedures, thereby increasing hospital costs. The Uniform Policy Provision Law (UPPL) exists in many states and allows insurance companies to deny payment for medical treatment for alcohol-related injuries. If intoxication increases resource utilization, these denials compound the financial burden of alcohol use on trauma centers. We hypothesized that patients injured while under the influence of alcohol require more diagnostic tests, procedures, and hospital admissions, leading to higher hospital charges. METHODS: The National Trauma Databank (2000-2004) was analyzed to identify adult trauma patients (age > or = 16 years) who were discharged alive, had a length of stay < or = 1 day and minor injuries (Injury Severity Score < 9), and were tested for blood alcohol. The study was confined to minimally injured patients to facilitate identification of unexpected resource use most likely attributable to alcohol use. Resource utilization was compared among patients who tested positive or negative for alcohol use. Results are presented as odds ratio (OR) with 95% confidence intervals (CI). RESULTS: Sixty-eight thousand eight patients met study criteria, of which 31,020 were positive for alcohol. Despite similar baseline characteristics, alcohol-positive patients required significantly more invasive procedures, including intubation (OR 4.16, 95% CI = 3.56-4.85) and Foley catheter insertion (OR 1.52, 95% CI = 1.39-1.67) as well as diagnostic tests (CT scan OR 1.16, 95% CI = 1.12-1.20). They were also less likely to be discharged from the emergency department (OR 0.61, 95% CI = 0.58-0.64), and more frequently required hospital (OR 1.64, 95% CI = 1.57-1.73) or intensive care unit admission (OR 1.82, 95% CI = 1.71-1.94). Mean hospital charges were $1,833 greater ($10,405 +/- 225 vs. 8,572 +/- 68). CONCLUSIONS: A significant amount of trauma center costs are primarily attributable to alcohol use rather than injury severity or outcome. The financial costs associated with alcohol use and UPPL-related cost-shifting to trauma centers is a significant burden to trauma centers. UPPL laws that penalize trauma centers for identifying intoxicated patients should be repealed in states where they exist.

Leukoreduction before red blood cell transfusion has no impact on mortality in trauma patients.

BACKGROUND: Studies suggest that leukocytes in donated blood increase mortality and length of hospital stay (LOS) after transfusion. These studies included few trauma patients, however. Many institutions now mandate leukoreduction (LR) of transfusion products, which increases costs by approximately $30/unit. The purpose of this study was to examine the effect of LR on mortality and LOS in trauma patients. METHODS: A retrospective before-and-after cohort study was conducted at a level one urban trauma center. LR of all transfusion products commenced in January 2002. All patients treated within the intervention period (March 2002 through January 2004) received LR products. Those transfused during March 2000 through January 2002 served as controls. The trauma registry was queried for patients >or=18 years who survived >or=2 days and received >or=2 units of blood. Mortality and LOS were determined for each group. Subset analysis was performed on patients receiving 2-6 transfusions and those receiving massive transfusion (>or=6 units). Mortality and LOS for control and intervention subsets were compared. Means were compared using Student's t-test, proportions using chi(2) (significance P