Motor vehicle collision characteristics and hospitalization outcomes associated with mild traumatic brain injury and concomitant whiplash injury.

OBJECTIVE: Few large studies have investigated the factors and outcomes related to concomitant injuries occurring alongside mild traumatic brain injury (mTBI) after motor vehicle collisions (MVCs). Thus, the objective of this study was to assess whether MVC characteristics predict which patients with mTBI will have concomitant whiplash injury, and whether concomitant whiplash injury affects care utilization for these patients. METHODS: This retrospective cohort study included 22,213 patients with mTBI after MVC identified from the American College of Surgeons Trauma Quality Programs dataset. A hierarchical logistic regression model was constructed to investigate patient and MVC factors associated with concomitant whiplash injury. Propensity score matching on whiplash status, in conjunction with a multivariable logistic regression model, assessed if concomitant whiplash affected odds of hospitalization. In the subgroup of patients who were hospitalized, associations with hospital length of stay (LOS) and discharge disposition were investigated. RESULTS: The median (IQR) age was 34 (24-51) years, with a median Glasgow Coma Scale score at presentation of 15 (15-15). Patients with concomitant whiplash were older (median 36 years vs 34 years, p = 0.03) and had higher rates of hospitalization (75% vs 64%, p < 0.001). In the hierarchical model for associations with concomitant whiplash injury, patients with blood alcohol content (BAC) greater than the federal driving limit had lower odds of concomitant whiplash (OR 0.63, 95% CI 0.49-0.81) along with those who had airbag deployment (OR 0.80, 95% CI 0.68-0.95), but seatbelt use was associated with greater odds (OR 1.41, 95% CI 1.16-1.71). After matching, concomitant whiplash was independently associated with increased odds of hospitalization (OR 1.67, 95% CI 1.40-1.99) while seatbelt use was associated with decreased odds (OR 0.88, 95% CI 0.81-0.95). Among hospitalized patients, concomitant whiplash was not associated with hospital LOS or discharge disposition. CONCLUSIONS: MVC characteristics such as alcohol consumption and airbag deployment were protective toward development of concomitant whiplash for mTBI patients, while seatbelt use was associated with higher risk. Concomitant whiplash increases the odds of hospitalization for mTBI patients but does not affect hospital LOS or discharge disposition, while seatbelt use is associated with lower rates of hospitalization and a more favorable hospital course. These findings provide context to injury patterns and care provision after a common mechanism of injury.

Modifiable Factors Related to Firearm Homicides: A Broader View of Our Lane.

OBJECTIVE: This study aims to identify modifiable factors related to firearm homicide (FH). SUMMARY BACKGROUND DATA: Many socioeconomic, legislative and behavioral risk factors impact FH. Most studies have evaluated these risk factors in isolation, but they coexist in a complex and ever-changing American society. We hypothesized that both restrictive firearm laws and socioeconomic support would correlate with reduced FH rates. METHODS: To perform our ecologic cross-sectional study, we queried the Centers for Disease Control (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) and Federal Bureau of Investigation (FBI) Uniform Crime Reporting (UCR) for 2013-2016 state FH data. We retrieved firearm access estimates from the RAND State-Level Firearm Ownership Database. Alcohol use and access to care data were captured from the CDC Behavioral Risk Factor Surveillance System (BRFSS). Detached youth rates, socioeconomic support data and poverty metrics were captured from US Census data for each state in each year. Firearm laws were obtained from the State Firearms Law Database. Variables with significant FH association were entered into a final multivariable panel linear regression with fixed effect for state. RESULTS: A total of 49,610 FH occurred in 2013-2016 (median FH rate: 3.9:100,000, range: 0.07-11.2). In univariate analysis, increases in concealed carry limiting laws ( P =0.012), detached youth rates ( P <0.001), socioeconomic support ( P <0.001) and poverty rates ( P <0.001) correlated with decreased FH. Higher rates of heavy drinking ( P =0.036) and the presence of stand your ground doctrines ( P =0.045) were associated with increased FH. Background checks, handgun limiting laws, and weapon access were not correlated with FH. In multivariable regression, increased access to food benefits for those in poverty [ß: -0.132, 95% confidence interval (CI): -0.182 to -0.082, P <0.001] and laws limiting concealed carry (ß: -0.543, 95% CI: -0.942 to -0.144, P =0.008) were associated with decreased FH rates. Allowance of stand your ground was associated with more FHs (ß: 1.52, 95% CI: 0.069-2.960, P <0.040). CONCLUSIONS: The causes and potential solutions to FH are complex and closely tied to public policy. Our data suggests that certain types of socioeconomic support and firearm restrictive legislation should be emphasized in efforts to reduce firearm deaths in America.

A Pilot Machine Learning Study Using Trauma Admission Data to Identify Risk for High Length of Stay.

INTRODUCTION: Trauma patients have diverse resource needs due to variable mechanisms and injury patterns. The aim of this study was to build a tool that uses only data available at time of admission to predict prolonged hospital length of stay (LOS). METHODS: Data was collected from the trauma registry at an urban level one adult trauma center and included patients from 1/1/2014 to 3/31/2019. Trauma patients with one or fewer days LOS were excluded. Single layer and deep artificial neural networks were trained to identify patients in the top quartile of LOS and optimized on area under the receiver operator characteristic curve (AUROC). The predictive performance of the model was assessed on a separate test set using binary classification measures of accuracy, precision, and error. RESULTS: 2953 admitted trauma patients with more than one-day LOS were included in this study. They were 70% male, 60% white, and averaged 47 years-old (SD: 21). 28% were penetrating trauma. Median length of stay was 5 days (IQR 3-9). For prediction of prolonged LOS, the deep neural network achieved an AUROC of 0.80 (95% CI: 0.786-0.814) specificity was 0.95, sensitivity was 0.32, with an overall accuracy of 0.79. CONCLUSION: Machine learning can predict, with excellent specificity, trauma patients who will have prolonged length of stay with only physiologic and demographic data available at the time of admission. These patients may benefit from additional resources with respect to disposition planning at the time of admission.

Use of Cold-Stored Whole Blood is Associated With Improved Mortality in Hemostatic Resuscitation of Major Bleeding: A Multicenter Study.

OBJECTIVE: The aim of this study was to identify a mortality benefit with the use of whole blood (WB) as part of the resuscitation of bleeding trauma patients. BACKGROUND: Blood component therapy (BCT) is the current standard for resuscitating trauma patients, with WB emerging as the blood product of choice. We hypothesized that the use of WB versus BCT alone would result in decreased mortality. METHODS: We performed a 14-center, prospective observational study of trauma patients who received WB versus BCT during their resuscitation. We applied a generalized linear mixed-effects model with a random effect and controlled for age, sex, mechanism of injury (MOI), and injury severity score. All patients who received blood as part of their initial resuscitation were included. Primary outcome was mortality and secondary outcomes included acute kidney injury, deep vein thrombosis/pulmonary embolism, pulmonary complications, and bleeding complications. RESULTS: A total of 1623 [WB: 1180 (74%), BCT: 443(27%)] patients who sustained penetrating (53%) or blunt (47%) injury were included. Patients who received WB had a higher shock index (0.98 vs 0.83), more comorbidities, and more blunt MOI (all P <0.05). After controlling for center, age, sex, MOI, and injury severity score, we found no differences in the rates of acute kidney injury, deep vein thrombosis/pulmonary embolism or pulmonary complications. WB patients were 9% less likely to experience bleeding complications and were 48% less likely to die than BCT patients ( P <0.0001). CONCLUSIONS: Compared with BCT, the use of WB was associated with a 48% reduction in mortality in trauma patients. Our study supports the use of WB use in the resuscitation of trauma patients.

Duodenal-Jejunal Bypass Liner for the management of Type 2 Diabetes Mellitus and Obesity: A Multicenter Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to examine the clinical efficacy and safety of the duodenal-jejunal bypass liner (DJBL) while in situ for 12 months and for 12 months after explantation. SUMMARY BACKGROUND DATA: This is the largest randomized controlled trial (RCT) of the DJBL, a medical device used for the treatment of people with type 2 diabetes mellitus (T2DM) and obesity. Endoscopic interventions have been developed as potential alternatives to those not eligible or fearful of the risks of metabolic surgery. METHODS: In this multicenter open-label RCT, 170 adults with inadequately controlled T2DM and obesity were randomized to intensive medical care with or without the DJBL. Primary outcome was the percentage of participants achieving a glycated hemoglobin reduction of ≥20% at 12 months. Secondary outcomes included weight loss and cardiometabolic risk factors at 12 and 24 months. RESULTS: There were no significant differences in the percentage of patients achieving the primary outcome between both groups at 12 months [DJBL 54.6% (n = 30) vs control 55.2% (n = 32); odds ratio (OR) 0.93, 95% confidence interval (CI): 0.44-2.0; P = 0.85]. Twenty-four percent (n = 16) patients achieved ≥15% weight loss in the DJBL group compared to 4% (n = 2) in the controls at 12 months (OR 8.3, 95% CI: 1.8-39; P = .007). The DJBL group experienced superior reductions in systolic blood pressure, serum cholesterol, and alanine transaminase at 12 months. There were more adverse events in the DJBL group. CONCLUSIONS: The addition of the DJBL to intensive medical care was associated with superior weight loss, improvements in cardiometabolic risk factors, and fatty liver disease markers, but not glycemia, only while the device was in situ. The benefits of the devices need to be balanced against the higher rate of adverse events when making clinical decisions. TRIAL REGISTRATION: ISRCTN30845205. isrctn.org; Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership reference 12/10/04.

Pain Interference and Decreased Physical Function After Emergency General Surgery: Measuring Patient-Reported Outcomes.

INTRODUCTION: There is increasing emphasis on patient-reported outcomes (PROs) measures in healthcare, but this area remains largely unexplored in emergency general surgery (EGS) conditions. We hypothesized that postoperative patients in our EGS clinic would report detrimental changes in several domains of health-related quality of life (HRQoL). METHODS: We administered the PROMIS-29, a HRQoL measurement tool, to postoperative patients in our EGS clinic (11/2019-4/2020). Patients responded to measures of 7 domains. Domain scores were converted to t-scores, allowing comparison to average values within the general US population (set to 50 by definition). We report the mean scores within each domain. Higher scores in negatively worded domains (e.g., "Depression") are worse; vice versa for positively worded domains (e.g., "Physical Function"). Changes in scores at subsequent clinic visits were analyzed using the paired t-test. RESULTS: There were 97 patients who completed the PROMIS-29 at the first postoperative visit. Mean (SD) age was 54.1 (16.2) years; 51% were male. There was no difference in our patients from the average US population in the domains of Ability to Participate in Social Roles and Activities, Anxiety, Fatigue, and Sleep Disturbance. However, EGS patients experienced significantly greater Pain Interference (56.1 [54.1, 58.1]) and worse Physical Function (40.6 [38.4, 42.7]) than average. For patients seen in follow-up twice (13 patients, median interval between clinic visits 21 days), there were improvements in the domains of Physical Function (42.9 vs 37.3; p = 0.04) and Fatigue. CONCLUSION: We demonstrate room for improvement in the domains of pain interference and physical function. While positive changes over a relatively short period of time are encouraging, consideration should be given to patient perceptions of illness and lifestyle impact when managing EGS patients.

Increased Rate of Long-term Mortality Among Burn Survivors: A Population-based Matched Cohort Study.

OBJECTIVE: To estimate long-term mortality following major burn injury compared with matched controls. SUMMARY BACKGROUND DATA: The effect of sustaining a major burn injury on long-term life expectancy is poorly understood. METHODS: Using health administrative data, all adults who survived to discharge after major burn injury between 2003 and 2013 were matched to between 1 and 5 uninjured controls on age, sex, and the extent of both physical and psychological comorbidity. To account for socioeconomic factors such as residential instability and material deprivation, we also matched on marginalization index. The primary outcome was 5-year all-cause mortality, and all patients were followed until death or March 31, 2014. Cumulative mortality estimates were estimated using the Kaplan-Meier method. Cox proportional hazards modeling was used to estimate the association of burn injury with mortality. RESULTS: In total, 1965 burn survivors of mean age 44 (standard deviation 17) years with median total body surface area burn of 15% [interquartile range (IQR) 5-15] were matched to 8671 controls and followed for a median 5 (IQR 2.5-8) years. Five-year mortality was significantly greater among burn survivors (11 vs 4%, P < 0.001). The hazard ratio was greatest during the first year (4.15, 95% CI 3.17-5.42), and declined each year thereafter, reaching 1.65 (95% CI 1.02-2.67) in the fifth year after discharge. Burn survivors had increased mortality related to trauma (mortality rate ratio, MRR 9.8, 95% CI 5-19) and mental illness (MRR 9.1, 95% CI 4-23). CONCLUSIONS: Burn survivors have a significantly higher rate of long-term mortality than matched controls, particularly related to trauma and mental illness. Burn follow-up should be focused on injury prevention, mental healthcare, and detection and treatment of new disease.

Isolated Traumatic Subarachnoid Hemorrhage: An Evaluation of Critical Care Unit Admission Practices and Outcomes From a North American Perspective.

OBJECTIVES: Traumatic subarachnoid hemorrhage is a common radiographic finding associated with traumatic brain injury. The objective of this investigation is to evaluate the association between hospital-level ICU admission practices and clinically important outcomes for patients with isolated traumatic subarachnoid hemorrhage and mild clinical traumatic brain injury. DESIGN: Multicenter observational cohort. SETTING: Trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program spanning January 2012 to March 2014. PATIENTS: A total of 14,146 subjects, 16 years old and older, admitted to 215 trauma centers with isolated traumatic subarachnoid hemorrhage and Glasgow Coma Scale score 13 or greater. Patients with concurrent intracranial injuries, severe injury to other body regions, or tests positive for alcohol or illicit substances were excluded. INTERVENTION: ICU admission. MEASUREMENTS AND MAIN RESULTS: The primary outcome was need for neurosurgical intervention, defined as insertion of an intracranial monitor/drain or craniectomy/craniotomy. Secondary outcomes describing the clinical course included hospital discharge disposition, in-hospital mortality, and length of stay. Admission to ICU was common within the cohort (44.6%), yet the need for neurosurgical intervention was rare (0.24%). Variability was high between centers and remained so after adjusting for differences in case-mix and hospital-level characteristics (median odds ratio, 4.1). No significant differences in neurosurgical interventions, mortality, or discharge disposition to home under self-care were observed between groups of the highest and lowest ICU admitting hospitals. However, those in highest admitting group "stayed" in hospital 1.13 (95% CI, 1.07-1.20; p < 0.001) times that of the lowest admitting group. CONCLUSIONS: Critical care admission for mild traumatic brain injury patients with isolated traumatic subarachnoid hemorrhage is frequent and highly variable despite low probability of requiring neurosurgical intervention. Reevaluation of hospital-level practices may represent an opportunity for resource optimization when managing patients with mild clinical traumatic brain injury and associated isolated traumatic subarachnoid hemorrhage.

Reporting and evaluating wait times for urgent hip fracture surgery in Ontario, Canada.

BACKGROUND: Although a delay of 24 hours for hip fracture repair is associated with medical complications and costs, it is unknown how long patients wait for surgery for hip fracture. We describe novel methods for measuring exact urgent and emergent surgical wait times (in hours) and the factors that influence them. METHODS: Adults aged 45 years and older who underwent surgery for hip fracture (the most common urgently performed procedure) in Ontario, Canada, between 2009 and 2014 were eligible. Validated data from linked health administrative databases were used. The primary outcome was the time elapsed from hospital arrival recorded in the National Ambulatory Care Reporting System until the time of surgery recorded in the Discharge Abstract Database (in hours). The influence of patient, physician and hospital factors on wait times was investigated using 3-level, hierarchical linear regression models. RESULTS: Among 42 230 patients with hip fracture, the mean (SD) wait time for surgery was 38.76 (28.84) hours, and 14 174 (33.5%) patients underwent surgery within 24 hours. Variables strongly associated with delay included time for hospital transfer (adjusted increase of 26.23 h, 95% CI 25.38 to 27.01) and time for preoperative echocardiography (adjusted increase of 18.56 h, 95% CI 17.73 to 19.38). More than half of the hospitals (37 of 72, 51.4%), compared with 4.8% of surgeons and 0.2% of anesthesiologists, showed significant differences in the risk-adjusted likelihood of delayed surgery. INTERPRETATION: Exact wait times for urgent and emergent surgery can be measured using Canada's administrative data. Only one-third of patients received surgery within the safe time frame (24 h). Wait times varied according to hospital and physician factors; however, hospital factors had a larger impact.

Timing of femoral shaft fracture fixation following major trauma: A retrospective cohort study of United States trauma centers.

BACKGROUND: Femoral shaft fractures are common in major trauma. Early definitive fixation, within 24 hours, is feasible in most patients and is associated with improved outcomes. Nonetheless, variability might exist between trauma centers in timeliness of fixation. Such variability could impact outcomes and would therefore represent a target for quality improvement. We evaluated variability in delayed fixation (≥24 hours) between trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and measured the resultant association with important clinical outcomes at the hospital level. METHODS AND FINDINGS: A retrospective cohort study was performed using data derived from the ACS TQIP database. Adults with severe injury who underwent definitive fixation of a femoral shaft fracture at a level I or II trauma center participating in ACS TQIP (2012-2015) were included. Patient baseline and injury characteristics that might affect timing of fixation were considered. A hierarchical logistic regression model was used to identify predictors of delayed fixation. Hospital variability in delayed fixation was measured using 2 approaches. First, the random effects output of the hierarchical model was used to identify outlier hospitals where the odds of delayed fixation were significantly higher or lower than average. Second, the median odds ratio (MOR) was calculated to quantify heterogeneity in delayed fixation between hospitals. Finally, complications (pulmonary embolism, deep vein thrombosis, acute respiratory distress syndrome, pneumonia, decubitus ulcer, and death) and hospital length of stay were compared across quartiles of risk-adjusted delayed fixation. We identified 17,993 patients who underwent definitive fixation at 216 trauma centers. The median injury severity score (ISS) was 13 (interquartile range [IQR] 9-22). Median time to fixation was 15 hours (IQR 7-24 hours) and delayed fixation was performed in 26% of patients. After adjusting for patient characteristics, 57 hospitals (26%) were identified as outliers, reflecting significant practice variation unexplained by patient case mix. The MOR was 1.84, reflecting heterogeneity in delayed fixation across centers. Compared to hospitals in the lowest quartile of delayed fixation, patients treated at hospitals in the highest quartile of delayed fixation suffered 2-fold higher rates of pulmonary embolism (2.6% versus 1.3%; rate ratio [RR] 2.0; 95% CI 1.2-3.2; P = 0.005) and required greater length of stay (7 versus 6 days; RR 1.15; 95% CI 1.1-1.19; P < 0.001). There was no significant difference with respect to mortality (1.3% versus 0.8%; RR 1.6; 95% CI 1.0-2.8; P = 0.066). The main limitations of this study include the inability to classify fractures by severity, challenges related to the heterogeneity of the study population, and the potential for residual confounding due to unmeasured factors. CONCLUSIONS: In this large cohort study of 216 trauma centers, significant practice variability was observed in delayed fixation of femoral shaft fractures, which could not be explained by differences in patient case mix. Patients treated at centers where delayed fixation was most common were at significantly greater risk of pulmonary embolism and required longer hospital stay. Trauma centers should strive to minimize delays in fixation, and quality improvement initiatives should emphasize this recommendation in best practice guidelines.

Laparoscopic Surgery for Adhesive Small Bowel Obstruction Is Associated With a Higher Risk of Bowel Injury: A Population-based Analysis of 8584 Patients.

OBJECTIVE: We set out to compare the incidence of bowel repair and/or resection in a large cohort of patients with adhesive small bowel obstruction (SBO) managed operatively. BACKGROUND: Laparoscopic lysis of adhesions for adhesive SBO (aSBO) is becoming more common, yet might increase the risk of bowel injury given the distended and/or potentially compromised small bowel. METHODS: We used administrative discharge data derived from a large geographic region, identifying patients who underwent surgery for their first episode of aSBO during 2005 to 2014. Procedure codes were used to determine the exposure: either an open approach or a laparoscopic approach (including procedures converted to open). The primary outcome was incidence of bowel intervention, defined as intraoperative enterotomy, suture repair of intestine, or bowel resection. We estimated the odds of bowel intervention after adjusting for patient and clinical factors. RESULTS: A total of 8584 patients underwent operation for aSBO. Patients undergoing laparoscopic procedures were younger with fewer comorbid conditions. The rate of laparoscopic approaches increased more than 3-fold during the study period (4.3%-14.3%, P < 0.0001). The incidence of bowel intervention was 53.5% versus 43.4% in laparoscopic versus open procedures (P < 0.0001). After adjustment for potential confounders, the odds of bowel intervention among patients treated laparoscopically versus open was 1.6 (95% confidence interval: 1.4-1.9). CONCLUSIONS: Laparoscopic procedures for aSBO are associated with a greater likelihood of intervention for bowel injury and/or repair. This increase might be due to challenges inherent with laparoscopic approaches in patients with distended small bowel. Surgeons should approach laparoscopic lysis of adhesions with a higher level of awareness and use strategies to mitigate this risk.

Tumour infiltrating lymphocytes correlate with improved survival in patients with oesophageal adenocarcinoma.

BACKGROUND: Oesophageal adenocarcinoma (OAC) is increasingly common in the west, and survival remains poor at 10-15 % at 5 years. Immune responses are increasingly implicated as a determining factor of tumour progression. The ability of lymphocytes to recognise tumour antigens provides a mechanism for a host immune attack against cancer providing a potential treatment strategy. MATERIALS AND METHODS: Tumour infiltrating lymphocytes (TILs: CD3+, CD4+, CD8+ and FOXp3+) were assessed by immunohistochemistry using tissue microarrays in a contemporary and homogeneous cohort of OAC patients (n = 128) undergoing curative treatment. RESULTS: Multivariate analysis identified three independent prognostic factors for improved cancer-specific survival (CSS): increased CD8+ TILs (p = 0.003), completeness of resection (p < 0.0001) and lower pathological N stage (p < 0.0001). Independent prognostic factors for favourable disease-free survival included surgery-only treatment (p = 0.015), completeness of resection (p = 0.001), increased CD8+ TILs (p < 0.0001) and reduced pathological N stage (p < 0.0001). Higher levels of TILs in the pathological specimen were associated with significant pathological response to neoadjuvant chemotherapy (NAC). On multivariate analysis increased levels of CD4+ (p = 0.017) and CD8+ TILs (p = 0.005) were associated with significant local tumour regression and lymph node downstaging, respectively. DISCUSSION: Our results establish an association of TILs and survival in OAC, as seen in other solid tumours, and identify particular TIL subsets that are present at higher levels in patients who responded to NAC compared to non-responders. These findings highlight potential therapeutic strategies in EAC based on utilising the host immunological response and highlight the immune responses biomarker potential.

The relevance of the Siewert classification in the era of multimodal therapy for adenocarcinoma of the gastro-oesophageal junction.

INTRODUCTION: The Siewert classification has been used to plan treatment for tumours of the gastro-oesophageal junction since its proposal in the 1980s. The purpose of this study was to assess its continued relevance by evaluating whether there were differences in the biology and clinical characteristics of adenocarcinomas by Siewert type, in a contemporary cohort of patients, in whom the majority had received neoadjuvant chemotherapy. METHODS: A prospective database was reviewed for all patients who underwent resection from 2005 to 2011 and analysed with regard to Siewert classification determined from the pathological specimen, treatment and clinicopathological outcomes. RESULTS: Two hundred and sixteen patients underwent oesophagogastric resection: 133 for type I, 51 for type II and 33 for type III tumours. 135 Patients (62.5%) received neoadjuvant chemotherapy with no difference between groups. There were no significant differences in age, sex, pT stage, pN stage, pM stage, ASA, or inpatient complications between patients with adenocarcinoma based on their Siewert classification. There was a significant increase in maximum tumour diameter (P = 0.023), perineural invasion (P = 0.021) and vascular invasion (P = 0.020), associated with more distal tumours (Type III > Type II > Type I). Median overall survival was significantly shorter for more distal tumours (Type I: 4.96 years vs. Type II: 3.3 years vs. Type III: 2.64 years; P = 0.04). The surgical approach did not influence survival. CONCLUSION: In the era of multi-modal treatment pathological Siewert tumour type is of prognostic value, as patients with Type III disease are likely to have larger and more aggressive tumours that lead to worse outcomes.

Gender-specific differences in left ventricular remodelling in obesity: insights from cardiovascular magnetic resonance imaging.

AIMS: As obesity-related cardiovascular mortality, although elevated when compared with normal weight, is lower in females than in males at every body mass index (BMI) level, we aimed to investigate gender-specific differences in left ventricular (LV) hypertrophy in obesity, which themselves have been shown to have varying prognostic value. METHOD AND RESULTS: In total, 741 subjects (female, n = 399) without identifiable cardiovascular risk factors (BMI 15.7-59.2 kg/m(2)) underwent cardiovascular magnetic resonance (1.5 T) to determine LV mass, end-diastolic volume (EDV, mL), and LV mass/volume ratio (LVM/VR). Across both sexes, there was a strong positive correlation between BMI and LV mass (male r = 0.44, female r = 0.57, both P < 0.001), with males showing a greater LV hypertrophic response (male +2.3 vs. female +1.6 g per BMI point increase, P = 0.001). Concentric hypertrophy was present in both sexes and LVM/VR positively correlated to BMI (male r = 0.45, female r = 0.29, both P < 0.001) on linear regression analysis. However, the degree of concentric hypertrophy was greater in males (male +0.13 vs. female +0.06 LVM/VR increase per BMI point increase, P = 0.001). On the other hand, females showed a greater LV cavity dilatory response (female +1.1 vs. male +0.3 mL per BMI point increase, P < 0.001). Indeed, in contrast to females, where BMI and LV-EDV were positively correlated (r = 0.38, P < 0.001), BMI did not correlate with EDV in men (r = 0.03, P = 0.62). CONCLUSION: In the absence of traditional cardiovascular risk factors, obese men show predominantly concentric hypertrophy, whereas obese women exhibit both eccentric and concentric hypertrophy. As concentric hypertrophy is more strongly related to cardiovascular mortality than eccentric hypertrophy, our observations may explain the observed gender difference in obesity-related mortality.

Robotic Technology in Emergency General Surgery Cases in the Era of Minimally Invasive Surgery.

Importance: Although robotic surgery has become an established approach for a wide range of elective operations, data on its utility and outcomes are limited in the setting of emergency general surgery. Objectives: To describe temporal trends in the use of laparoscopic and robotic approaches and compare outcomes between robotic and laparoscopic surgery for 4 common emergent surgical procedures. Design, Setting, and Participants: A retrospective cohort study of an all-payer discharge database of 829 US facilities was conducted from calendar years 2013 to 2021. Data analysis was performed from July 2022 to November 2023. A total of 1 067 263 emergent or urgent cholecystectomies (n = 793 800), colectomies (n = 89 098), inguinal hernia repairs (n = 65 039), and ventral hernia repairs (n = 119 326) in patients aged 18 years or older were included. Exposure: Surgical approach (robotic, laparoscopic, or open) to emergent or urgent cholecystectomy, colectomy, inguinal hernia repair, or ventral hernia repair. Main Outcomes and Measures: The primary outcome was the temporal trend in use of each operative approach (laparoscopic, robotic, or open). Secondary outcomes included conversion to open surgery and length of stay (both total and postoperative). Temporal trends were measured using linear regression. Propensity score matching was used to compare secondary outcomes between robotic and laparoscopic surgery groups. Results: During the study period, the use of robotic surgery increased significantly year-over-year for all procedures: 0.7% for cholecystectomy, 0.9% for colectomy, 1.9% for inguinal hernia repair, and 1.1% for ventral hernia repair. There was a corresponding decrease in the open surgical approach for all cases. Compared with laparoscopy, robotic surgery was associated with a significantly lower risk of conversion to open surgery: cholecystectomy, 1.7% vs 3.0% (odds ratio [OR], 0.55 [95% CI, 0.49-0.62]); colectomy, 11.2% vs 25.5% (OR, 0.37 [95% CI, 0.32-0.42]); inguinal hernia repair, 2.4% vs 10.7% (OR, 0.21 [95% CI, 0.16-0.26]); and ventral hernia repair, 3.5% vs 10.9% (OR, 0.30 [95% CI, 0.25-0.36]). Robotic surgery was associated with shorter postoperative lengths of stay for colectomy (-0.48 [95% CI, -0.60 to -0.35] days), inguinal hernia repair (-0.20 [95% CI, -0.30 to -0.10] days), and ventral hernia repair (-0.16 [95% CI, -0.26 to -0.06] days). Conclusions and Relevance: While robotic surgery is still not broadly used for emergency general surgery, the findings of this study suggest it is becoming more prevalent and may be associated with better outcomes as measured by reduced conversion to open surgery and decreased length of stay.

Increasing Injury Intensity among 6,500 Violent Deaths in the State of Maryland.

BACKGROUND: Anecdotal evidence strongly suggests there has been a rise in violent crimes. This study sought to examine trends in injury characteristics of homicide victims in Maryland. We hypothesized that there would be an increase in the severity of wound characteristics. STUDY DESIGN: The Office of the Chief Medical Examiner is a statewide agency designated by law to investigate all homicides, suicides, or unusual or suspicious circumstances. Using individual autopsy reports, we collected data among all homicides from 2005 to 2017, categorizing them into 3 time periods: 2005 to 2008 (early), 2009 to 2013 (mid), and 2014 to 2017 (late). Primary outcomes included the number of gunshots, stabs, and fractures from assaults. High-violence intensity outcomes included victims having 10 or more gunshots, 5 or more stabs, or 5 or more fractures from assaults. RESULTS: Of 6,500 homicides (annual range 403 to 589), the majority were from firearms (75%), followed by stabbings (14%) and blunt assaults (10%). Most homicide victims died in the hospital (60%). The average number of gunshots per victim was 3.9 (range 1 to 54), stabs per victim was 9.4 (range 1 to 563), and fractures from assaults per victim was 3.7 (range 0 to 31). The proportion of firearm victims with at least 10 gunshots nearly doubled from 5.7% in the early period to 10% (p < 0.01) in the late period. Similarly, the proportion with 5 or more stabbings increased from 39% to 50% (p = 0.02) and assault homicides with 5 or more fractures increased from 24% to 38% (p < 0.01). CONCLUSIONS: In Maryland, the intensity of violence increased across all major mechanisms of homicide. Further follow-up studies are needed to elucidate the root causes underlying this escalating trend.

Concomitant Traumatic Brain Injury Delays Surgery in Patients With Traumatic Spinal Cord Injury.

BACKGROUND AND OBJECTIVES: Growing evidence supports prompt surgical decompression for patients with traumatic spinal cord injury (tSCI). Rates of concomitant tSCI and traumatic brain injury (TBI) range from 10% to 30%. Concomitant TBI may delay tSCI diagnosis and surgical intervention. Little is known about real-world management of this common injury constellation that carries significant clinical consequences. This study aimed to quantify the impact of concomitant TBI on surgical timing in a national cohort of patients with tSCI. METHODS: Patient data were obtained from the National Trauma Data Bank (2007-2016). Patients admitted for tSCI and who received surgical intervention were included. Delayed surgical intervention was defined as surgery after 24 hours of admission. Multivariable hierarchical regression models were constructed to measure the risk-adjusted association between concomitant TBI and delayed surgical intervention. Secondary outcome included favorable discharge status. RESULTS: We identified 14 964 patients with surgically managed tSCI across 377 North American trauma centers, of whom 2444 (16.3%) had concomitant TBI and 4610 (30.8%) had central cord syndrome (CCS). The median time to surgery was 20.0 hours for patients without concomitant TBI and 24.8 hours for patients with concomitant TBI. Hierarchical regression modeling revealed that concomitant TBI was independently associated with delayed surgery in patients with tSCI (odds ratio [OR], 1.3; 95% CI, 1.1-1.6). Although CCS was associated with delayed surgery (OR, 1.5; 95% CI, 1.4-1.7), we did not observe a significant interaction between concomitant TBI and CCS. In the subset of patients with concomitant tSCI and TBI, patients with severe TBI were significantly more likely to experience a surgical delay than patients with mild TBI (OR, 1.4; 95% CI, 1.0-1.9). CONCLUSION: Concomitant TBI delays surgical management for patients with tSCI. This effect is largest for patients with tSCI with severe TBI. These findings should serve to increase awareness of concomitant TBI and tSCI and the likelihood that this may delay time-sensitive surgery.

Machine Learning Identifies Variation in Timing of Palliative Care Consultations Among Traumatic Brain Injury Patients.

Background and Objective Timely palliative care involvement offers demonstrable benefits for traumatic brain injury (TBI) patients; however, palliative care consultations (PCCs) are used inconsistently during TBI management. This study aimed to employ advanced machine learning techniques to elucidate the primary drivers of PCC timing variability for TBI patients. Methods Data on admission, hospital course, and outcomes were collected for a cohort of 232 TBI patients who received both PCCs and neurosurgical consultations during the same hospitalization. Principal Component Analysis (PCA) and K-means clustering were used to identify patient phenotypes, which were then compared using Kaplan-Meier analysis. An extreme gradient boosting model (XGBoost) was employed to determine drivers of PCC timing, with model interpretation performed using SHapley Additive exPlanations (SHAP). Results Cluster A (n = 86) consisted mainly of older (median [IQR] = 87 [78, 94] years), White females with mild TBIs and demonstrated the shortest time-to-PCC (2.5 [1.0, 7.0] days). Cluster B (n = 108) also sustained mild TBIs but comprised moderately younger (81 [75, 86] years) married White males with later PCC (5.0 [3.0, 10.8] days). Cluster C (n = 38) represented much younger (46.5 [29.5, 59.8] years), more severely injured, non-White patients with the latest PCC initiation (9.0 [4.2, 17.0] days). The clusters did not differ by discharge disposition (p = 0.4) or frequency inpatient mortality (p > 0.9); however, Kaplan-Meier analysis revealed a significant difference in the time from admission to PCC (p < 0.001), despite no differences in time from admission to mortality (p = 0.18). SHAP analysis of the XGBoost model identified age, sex, and race as the most influential drivers of PCC timing. Conclusions This study highlights crucial disparities in PCC timing for TBI patients and underscores the need for targeted strategies to ensure timely and equitable palliative care integration for this vulnerable population.

Quantifying the Association Between Surgical Spine Approach and Tracheostomy Timing After Traumatic Cervical Spinal Cord Injury.

BACKGROUND AND OBJECTIVES: Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI. METHODS: This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation. RESULTS: The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest. CONCLUSION: Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach.

Craniotomy versus craniectomy for traumatic acute subdural hematoma-coarsened exact matched analysis of outcomes.

BACKGROUND AND OBJECTIVES: Acute subdural hematoma (aSDH) after traumatic brain injury frequently requires emergent craniotomy (CO) or decompressive craniectomy (DC). We sought to determine the variables associated with either surgical approach and to compare outcomes between matched patients. METHODS: A multi-center retrospective review was used to identify traumatic aSDH patients who underwent CO or DC. Patient variables independently associated with surgical approach were used for coarsened exact matching.Multivariate logistic regression and multivariate Cox proportional-hazards regression wereconducted on matched patients to determine independent predictors of mortality. RESULTS: Seventy-six patients underwent CO and sixty-two underwent DC for aSDH evacuation. DC patients were21.4 years younger (P < 0.001), more likely to be male (80.6 % vs 60.5 %,P = 0.011), and present with GCS ≤ 8 (64.5 % vs 36.8 %,P = 0.001). Age (P < 0.001), epidural hematoma (P = 0.01), skull fracture (P = 0.001), and cisternal effacement (P = 0.02) were independently associated with surgical approach. After coarsened exact matching, DC (P = 0.008), older age (P = 0.007), male sex (P = 0.04), and intraventricular hemorrhage (P = 0.02), were independently associated with inpatient mortality. Multivariate Cox proportional-hazards regression demonstrated that DC was independently associated with mortality at 90-days (P = 0.001) and 1-year post-operation (P = 0.003). CONCLUSION: aSDH patients who receive surgical evacuation via DC as opposed to CO are younger, more likely to be male, and have worse clinical exam. After controlling for patient differences via coarsened exact matching, DC is independently associated with mortality.