Research and Scholarly Projects.

The idea of doing a research or scholarly project can be very daunting, however, the satisfaction of seeing a project to its completion is very rewarding. In this article, we provide medical students with guidance on whether they should take on a research or scholarly project during medical school, and how to get started, publish, and then present their project. We also highlight how such a project can benefit an applicant applying for residency training.

Health Disparities Investigator Development through a Team-Science Pilot Projects Program.

Profound health disparities are widespread among Native Hawaiians, other Pacific Islanders, and Filipinos in Hawai'i. Efforts to reduce and eliminate health disparities are limited by a shortage of investigators trained in addressing the genetic, socio economic, and environmental factors that contribute to disparities. In this conference proceedings report from the 2022 RCMI Consortium National Conference, we describe our mentoring program, with an emphasis on community-engaged research. Elements include our encouragement of a team-science, customized Pilot Projects Program (PPP), a Mentoring Bootcamp, and a mentoring support network. During 2017-2022, we received 102 PPP preproposals. Of these, 45 (48%) were invited to submit full proposals, and 22 (19%) were awarded (8 basic biomedical, 7 clinical, 7 behavioral). Eighty-three percent of awards were made to early-career faculty (31% ethnic minority, 72% women). These 22 awards generated 77 related publications; 84 new grants were submitted, of which 31 were awarded with a resultant return on investment of 5.9. From 5 to 11 investigators were supported by PPP awards each year. A robust usage of core services was observed. Our descriptive report (as part of a scientific conference session on RCMI specialized centers) focuses on a mentoring vehicle and shows how it can support early-stage investigators in pursuing careers in health disparities research.

Effectiveness of various COVID-19 vaccine regimens among 10.4 million patients from the National COVID Cohort Collaborative during Pre-Delta to Omicron periods - United States, 11 December 2020 to 30 June 2022.

OBJECTIVE: This study reports the vaccine effectiveness (VE) of COVID-19 vaccine regimens in the United States, based on the National COVID Cohort Collaborative (N3C) database. METHODS: Data from 10.4 million adults, enrolled in the N3C from 11 December 2020 to 30 June 2022, were analyzed. VE against infection and death outcomes were evaluated across 13 vaccine regimens in recipient cohorts during the Pre-Delta, Delta, and Omicron periods. VE was estimated as (1-odds ratio) × 100% by multivariate logistic regression, using the unvaccinated cohort as reference. RESULTS: Natural immunity showed a highly protective effect (70.33%) against re-infection, but the mortality risk among the unvaccinated population was increased after re-infection; vaccination following infection reduced the risk of re-infection and death. mRNA-1273 full vaccination plus mRNA-1273 booster showed the highest anti-infection effectiveness (47.59%) (95% CI, 46.72-48.45) in the overall cohort. In the type 2 diabetes cohort, VE against infection was highest with BNT162b2 full vaccination plus mRNA-1273 booster (61.19%) (95% CI, 53.73-67.75). VE against death was also highest with BNT162b2 full vaccination plus mRNA-1273 booster (89.56%) (95% CI, 85.75-92.61). During the Pre-Delta period, all vaccination regimens showed an anti-infection effect; during the Delta period, only boosters, mixed vaccines, and Ad26.COV2.S vaccination exhibited an anti-infection effect; during the Omicron period, none of the vaccine regimens demonstrated an anti-infection effect. Irrespective of the variant period, even a single dose of mRNA vaccine offered protection against death, thus demonstrating survival benefit, even in the presence of infection or re-infection. Similar patterns were observed in patients with type 2 diabetes. CONCLUSIONS: Although the anti-infection effect declined as SARS-CoV-2 variants evolved, all COVID-19 mRNA vaccines had sustained effectiveness against death. Vaccination was crucial for preventing re-infection and reducing the risk of death following SARS-CoV-2 infection.

Medical School Faculty and Staff Well-being in Fall 2020 during the COVID-19 Pandemic.

The COVID-19 pandemic increased stress and worry among faculty and staff members at universities across the US. To assess the well-being of university faculty and staff, a survey was administered at a medical school in the state of Hawai'i during early fall 2020. The purpose of the exploratory study was to assess and gauge faculty and staff members' well-being regarding the school's response to COVID-19. Participants in this study represented a convenience sample of compensated teaching, research, and administrative faculty and staff members. A total of 80 faculty and 73 staff members participated. Overall, faculty and staff reported relatively low levels of worries and stress. Staff members reported greater levels of worry and stress than faculty members in 8 of the 11 questions. Statistical differences were detected in 3 questions, with staff reporting higher levels of worry and stress in their health and well-being of themselves (P < .001), paying bills (P < .001), and losing their jobs (P < .001). Both faculty and staff reported good overall satisfaction on the timeliness and clarity of messages that they received, support from leadership and the school, and support to adjust to changes in response to COVID-19. For both faculty and staff, the greatest worry or concern for the open-ended question on worry and stress was related to financial and economic issues. Data from this survey and can contribute to an understanding of medical school employee well-being during a major operational disruption and may help develop policies and programs to assist employees in different employment categories during future disruptions.

Can lacrimal punctum size link to the severity of dry eye disease?

To investigate if larger punctum size links to the severity of dry eye disease (DED) and perhaps, punctum size inspection can be adopted to become one of the DED evaluations for practitioners. The records of 200 eyes of 114 patients that had temporary collagen punctum plugs due to severe DED (Level 2 to Level 4) from January 1, 2017, to July 31, 2018, were reviewed for the size of the plugs. Lacrimal punctum size of those eyes was approximated according to the size of vertical canalicular soft collagen plug (from 0.3 to 0.5 mm diameter, Oasis, Lacrimedics, Glendora, CA, USA). The dry eye severity grading from the International Dry Eye WorkShop was used to grade the level of the severity of DED. Those eyes classified as Level 2 and above were considered as severe due to the presentation of moderate-to-diffuse corneal staining and symptomatic. To assess if there is a correlation between punctum size and the severity of DED, the Spearman's rank correlation coefficient was calculated. Of the 200 Level 2 and above eyes, 131 (66%) eyes had a large punctum (≥0.5 mm). Punctum size larger than 0.4 mm was 95%. The estimated Spearman's ρ was 0.16. This indicates a statistical significant positive correlation (P = 0.02) between larger punctum size and higher level of DED. The larger size of lacrimal punctum may link to the severity of DED. Punctum inspection may be adopted to become one parameter for DED evaluation for practitioners.

Out-of-hospital decision making and factors influencing the regional distribution of injured patients in a trauma system.

BACKGROUND: The decision-making processes used for out-of-hospital trauma triage and hospital selection in regionalized trauma systems remain poorly understood. The objective of this study was to assess the process of field triage decision making in an established trauma system. METHODS: We used a mixed methods approach, including emergency medical services (EMS) records to quantify triage decisions and reasons for hospital selection in a population-based, injury cohort (2006-2008), plus a focused ethnography to understand EMS cognitive reasoning in making triage decisions. The study included 10 EMS agencies providing service to a four-county regional trauma system with three trauma centers and 13 nontrauma hospitals. For qualitative analyses, we conducted field observation and interviews with 35 EMS field providers and a round table discussion with 40 EMS management personnel to generate an empirical model of out-of-hospital decision making in trauma triage. RESULTS: A total of 64,190 injured patients were evaluated by EMS, of whom 56,444 (88.0%) were transported to acute care hospitals and 9,637 (17.1% of transports) were field trauma activations. For nontrauma activations, patient/family preference and proximity accounted for 78% of destination decisions. EMS provider judgment was cited in 36% of field trauma activations and was the sole criterion in 23% of trauma patients. The empirical model demonstrated that trauma triage is driven primarily by EMS provider "gut feeling" (judgment) and relies heavily on provider experience, mechanism of injury, and early visual cues at the scene. CONCLUSIONS: Provider cognitive reasoning for field trauma triage is more heuristic than algorithmic and driven primarily by provider judgment, rather than specific triage criteria.

Medical School Hotline: Turning the tragedy of tobacco around: how revenue from cigarettes improves health in Hawai'i.

JABSOM takes its responsibility to improve health among Hawai'i's people to heart. The school's vision is, ALOHA: to Attain Lasting Optimal Health for All, a theme adopted through a strategic planning process which engaged JABSOM's partners in the health and life sciences including its private sector collaborators and its sister colleges throughout the University of Hawai'i's ten-campus system. JABSOM's ability to collaborate and contribute in these areas has been irrevocably enhanced by tobacco-related funding that the State of Hawai'i has committed to develop the Kaka'ako campus. The taxpayers' generosity has improved the education and reach of clinicians and researchers who, in turn, dedicate their lives to preventing, treating and eliminating the deadly grip tobacco holds on too many of the people of Hawai'i.

Strengthening and Sustaining Inter-Institutional Research Collaborations and Partnerships.

Inter-institutional collaborations and partnerships play fundamental roles in developing and diversifying the basic biomedical, behavioral, and clinical research enterprise at resource-limited, minority-serving institutions. In conjunction with the Research Centers in Minority Institutions (RCMI) Program National Conference in Bethesda, Maryland, in December 2019, a special workshop was convened to summarize current practices and to explore future strategies to strengthen and sustain inter-institutional collaborations and partnerships with research-intensive majority-serving institutions. Representative examples of current inter-institutional collaborations at RCMI grantee institutions are presented. Practical approaches used to leverage institutional resources through collaborations and partnerships within regional and national network programs are summarized. Challenges and opportunities related to such collaborations are provided.

Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort.

STUDY OBJECTIVE: The first hour after the onset of out-of-hospital traumatic injury is referred to as the "golden hour," yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. METHODS: This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged > or =15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders. RESULTS: There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. CONCLUSION: In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

Injury hospitalization as a marker for emergency medical services use in elderly patients.

BACKGROUND: The elderly utilize emergency medical services (EMS) at a higher rate than younger patients, yet little is known about the influence of injury on subsequent EMS utilization and costs. OBJECTIVE: To assess injury hospitalization as a potential marker for subsequent EMS utilization and costs by Medicare patients. METHODS: This observational study analyzed a retrospective cohort of all Medicare patients (> or = 67 years old) with an International Classification of Diseases, Ninth Revision (ICD-9) injury diagnosis admitted to 125 Oregon and Washington hospitals during 2001 and 2002 who survived to hospital discharge. The numbers of EMS transports and the total EMS costs were compared one year before and one year following the index hospitalization. RESULTS: There were 30,655 injured elders in our cohort. Their median ICD-9-based injury severity score was 0.97, with 4.1% meeting a definition of serious injury and 37% having hip fractures. The mean (range) numbers of EMS transports before and after the injury were 0.5 (0-45) and 0.9 (0-56), for an unadjusted incidence rate ratio (IRR) of 1.7 (95% confidence interval [CI] 1.7-1.8). The increase in EMS utilization following an injury hospitalization was even greater after adjusting for risk period and other model predictors (IRR 2.4, 95% CI 2.3-2.5). Annual mean EMS costs rose 74% following the injury hospitalization, from $211 to $367 per person. The greatest increase was in nonemergent EMS use, accounting for 67% of the increase in the number of uses. Institutionalization in a skilled nursing or rehabilitation facility either before or after injury was strongly associated with the need for EMS care. CONCLUSION: An injury hospitalization in the elderly serves as a sentinel marker for an abrupt increase in EMS utilization and costs, even after accounting for confounders.

A critical assessment of the out-of-hospital trauma triage guidelines for physiologic abnormality.

BACKGROUND: It remains unclear whether the American College of Surgeons Committee on Trauma (ACSCOT) "step 1" field physiologic criteria could be further restricted without substantially sacrificing sensitivity. We assessed whether more restrictive physiologic criteria would improve the specificity of this triage step without missing high-risk patients. METHODS: We analyzed an out-of-hospital, consecutive patient, prospective cohort of injured adults >or=15 years collected from December 1, 2005, to February 28, 2007, by 237 emergency medical service agencies transporting to 207 acute care hospitals in 11 sites across the United States and Canada. Patients were included based on ACSCOT field decision scheme physiologic criteria systolic blood pressure 29 breaths/min, Glasgow Coma Scale score 2 days. RESULTS: Of 7,127 injured persons, 6,259 had complete outcome information and were included in the analysis. There were 3,631 (58.0%) persons with death or LOS >2 days. Using only physiologic measures, the derived rule included advanced airway intervention, shock index >1.4, Glasgow Coma Scale <11, and pulse oximetry <93%. Rule validation demonstrated sensitivity 72% (95% confidence interval: 70%-74%) and specificity 69% (95% confidence interval: 67%-72%). Inclusion of demographic and mechanism variables did not significantly improve performance measures. CONCLUSIONS: We were unable to omit or further restrict any ACSCOT step 1 physiologic measures in a decision rule practical for field use without missing high-risk trauma patients.

Remembering a critical triad in severe deceleration injuries to the chest: report of a traumatic aortic rupture case.

We aimed to present herein the case of a potentially preventable death involving traumatic aortic rupture and to develop a critical pathway for the management of isthmic aortic ruptures consistent with the available resources. A retrospective record review by a multidisciplinary panel of experts was done, and the probability of survival was estimated based on the Revised Trauma Score and Injury Severity Scale score. Literature review and expert consensus were used in a quality and safety analysis to develop a critical care pathway for future cases. A 32-year-old man, injured in a motorcycle accident, was referred to a trauma center in a state of shock. Thoracic aortic rupture was highly suspected. For educational purposes, the classic signs of a widened mediastinum, right tracheal deviation, and left-sided hemothorax (in a context of significant deceleration injury) are incorporated into an acute care triad for traumatic aortic rupture. In such cases, in the absence of poor access to aortography, we suggest (serial - if needed) contrast-enhanced chest computed tomography scanning for diagnosis confirmation and operative planning. Assumption of hemodynamic stability can be catastrophic, and transferring the patient to a second facility may endanger survival, when operative capacity exists at the initial trauma facility.

A geospatial analysis of persons opting out of an exception from informed consent out-of-hospital clinical trial.

STUDY OBJECTIVE: For trials involving exception from informed consent, some IRBs require that community members be allowed to "opt out" prior to enrollment. We tested for geospatial clustering of opt-out requests and the associated census tract characteristics in one study region. METHODS: This was a retrospective study at a single site of a multicenter exception from informed consent resuscitation trial. We collected and geocoded mailing addresses for persons requesting opt-out bracelets over 16 months, then tested for geospatial clustering using geographic information systems (GIS) analysis. Characteristics for tracts with and without bracelet clustering were compared using univariate tests, multivariable regression, and classification and regression tree (CART) analysis. RESULTS: We received 395 phone calls requesting 718 bracelets, of which 673 were analyzable. Of 397 census tracts in the region, 208 (52%) had at least one request and 38 (10%) demonstrated clustering. In multivariable models, an increasing proportion of family households (OR .90, 95%CI .85-.93), veterans (OR .91, 95%CI .81-1.02), and renters (OR .96, 95%CI .92-.99) were associated with lower odds of requesting an opt-out bracelet, while census tracts with higher income had higher odds of opting-out (OR 1.07, 95%CI 1.02-1.11). Using CART, the proportion of family households and graduate education identified the majority of opt-out requests by census tracts (cross-validation sensitivity 92%, specificity 56%). CONCLUSIONS: Opt-out requests for an exception from informed consent trial at one study site were geographically clustered and associated with certain population demographics. These findings may help identify key target groups for community consultation in future trials.

Rural Emergency Medicine: patient volume and training opportunities.

BACKGROUND: A paucity of board-certified Emergency Physicians practice in rural Emergency Departments (EDs). One proposed solution has been to train residents in rural EDs to increase the likelihood that they would continue to practice in rural EDs. Some within academic Emergency Medicine question whether rural hospital EDs can provide adequate patient volume for training an Emergency Medicine (EM) resident. STUDY OBJECTIVES: To compare per-physician patient-volumes in rural vs. urban hospital EDs in Oklahoma (OK) and the proportion of board-certified EM physicians in these two ED settings. METHODS: A 21-question survey was distributed to all OK hospital ED directors. Analysis was limited to non-military hospitals with EDs having an annual census > 15,000 patient visits. Comparisons were made between rural and urban EDs. RESULTS: There were 37 hospitals included in the analysis. Urban EDs had a higher proportion of board-certified EM physicians than rural EDs (80% vs. 28%). There were 4359 vs. 4470 patients seen per physician FTE (full-time equivalent) in the rural vs. urban ED settings, respectively (p = 0.84). CONCLUSIONS: Patient volumes per physician FTE do not differ in rural vs. urban OK hospital EDs, suggesting that an adequate volume of patients exists in rural EDs to support EM resident education. Proportionately fewer board-certified Emergency Physicians staff rural EDs. Opportunities to increase rural ED-based EM resident training should be explored.

Early neurosurgical procedures enhance survival in blunt head injury: propensity score analysis.

BACKGROUND: Studies of trauma systems have identified traumatic brain injury as a frequent cause of death or disability. Due to the heterogeneity of patient presentations, practice variations, and potential for secondary brain injury, the importance of early neurosurgical procedures upon survival remains controversial. Traditional observational outcome studies have been biased because injury severity and clinical prognosis are associated with use of such interventions. OBJECTIVE: We used propensity analysis to investigate the clinical efficacy of early neurosurgical procedures in patients with traumatic brain injury. METHODS: We analyzed a retrospectively identified cohort of 518 consecutive patients (ages 18-65 years) with blunt, traumatic brain injury (head Abbreviated Injury Scale score of >or= 3) presenting to the emergency department of a Level-1 trauma center. The propensity for a neurosurgical procedure (i.e., craniotomy or ventriculostomy) in the first 24 h was determined (based upon demographic, clinical presentation, head computed tomography scan findings, intracranial pressure monitor use, and injury severity). Multivariate logistic regression models for survival were developed using both the propensity for a neurosurgical procedure and actual performance of the procedure. RESULTS: The odds of in-hospital death were substantially less in those patients who received an early neurosurgical procedure (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.05-0.41). The mortality benefit of early neurosurgical intervention persisted after exclusion of patients who died within the first 24 h (OR 0.13; 95% CI 0.04-0.48). CONCLUSIONS: Analysis of observational data after adjustment using the propensity score for a neurosurgical procedure in the first 24 h supports the association of early neurosurgical intervention and patient survival in the setting of significant blunt, traumatic brain injury. Transfer of at-risk head-injured patients to facilities with high-level neurosurgical capabilities seems warranted.

A practical approach to the healthcare crisis: solutions for Hawai'i and the nation (Part 2 of 2).

We have previously reviewed the challenges facing Hawai'i and the nation in terms of healthcare. Successfully addressing these challenges will require major changes in the delivery of healthcare and societal/legal perspectives. In this issue, we outline the key factors needed collectively and simultaneously to address these challenges. These factors are: (1) a capitated care model focused on health and chronic disease management; (2) universal access to a basic healthcare delivery system, and acceptance of the service limitations associated with such a model of care delivery; (3) a universal electronic shared health information system as a mechanism by which care in such a system can be coordinated; (4) an approach to developing state sanctioned, legal approaches to avoiding or minimizing futile care; (5) enhancement of systems of care (e.g., statewide trauma systems); (6) alignment of practitioner and hospital reimbursement with societal health goals, with legal protections; (7) a system of no-fault patient compensation when injuries occur in the course of medical care; and (8) support of expanded training programs for physicians, nurses and other practitioners.

A practical approach to the healthcare crisis: the current challenges facing Hawai'i and the nation (part 1 of 2).

Although there is consensus regarding the existence of a healthcare crisis, that point is where the consensus stops, even within defined professional and demographic groups. Clearly there is evidence that we must address a growing societal expenditure for healthcare, an aging and more complex patient population, a shortage of physicians and other health care providers, and health outcomes disparities amongst population groups. This article emphasizes how these factors impact healthcare nationally and in Hawai'i. The second part of this series outlines approaches that can enhance health in the United States without creating economic collapse.

The Research Centers in Minority Institutions (RCMI) Translational Research Network: Building and Sustaining Capacity for Multi-Site Basic Biomedical, Clinical and Behavioral Research.

The Research Centers in Minority Institutions (RCMI) program was established by the US Congress to support the development of biomedical research infrastructure at minority-serving institutions granting doctoral degrees in the health professions or in a health-related science. RCMI institutions also conduct research on diseases that disproportionately affect racial and ethnic minorities (ie, African Americans/Blacks, American Indians and Alaska Natives, Hispanics, Native Hawaiians and Other Pacific Islanders), those of low socioeconomic status, and rural persons. Quantitative metrics, including the numbers of doctoral science degrees granted to underrepresented students, NIH peer-reviewed research funding, peer-reviewed publications, and numbers of racial and ethnic minorities participating in sponsored research, demonstrate that RCMI grantee institutions have made substantial progress toward the intent of the Congressional legislation, as well as the NIH/NIMHD-linked goals of addressing workforce diversity and health disparities. Despite this progress, nationally, many challenges remain, including persistent disparities in research and career development awards to minority investigators. The continuing underrepresentation of minority investigators in NIH-sponsored research across multiple disease areas is of concern, in the face of unrelenting national health inequities. With the collaborative network support by the RCMI Translational Research Network (RTRN), the RCMI community is uniquely positioned to address these challenges through its community engagement and strategic partnerships with non-RCMI institutions. Funding agencies can play an important role by incentivizing such collaborations, and incorporating metrics for research funding that address underrepresented populations, workforce diversity and health equity.

Resuscitation Outcomes Consortium (ROC) PRIMED cardiac arrest trial methods part 1: rationale and methodology for the impedance threshold device (ITD) protocol.

AIM: The primary aim of this study is to compare survival to hospital discharge with a modified Rankin score (MRS)< or =3 between standard cardiopulmonary resuscitation (CPR) plus an active impedance threshold device (ITD) versus standard CPR plus a sham ITD in patients with out-of-hospital cardiac arrest. Secondary aims are to compare functional status and depression at discharge and at 3 and 6 months post-discharge in survivors. DESIGN: Prospective, double-blind, randomized, controlled, clinical trial. POPULATION: Patients with non-traumatic out-of-hospital cardiac arrest treated by emergency medical services (EMS) providers. SETTING: EMS systems participating in the Resuscitation Outcomes Consortium. SAMPLE SIZE: Based on a one-sided significance level of 0.025, power=0.90, a survival with MRS< or =3 to discharge rate of 5.33% with standard CPR and sham ITD, and two interim analyses, a maximum of 14,742 evaluable patients are needed to detect a 6.69% survival with MRS< or =3 to discharge with standard CPR and active ITD (1.36% absolute survival difference). CONCLUSION: If the ITD demonstrates the hypothesized improvement in survival, it is estimated that 2700 deaths from cardiac arrest per year would be averted in North America alone.

Establishing the need for trauma center care: anatomic injury or resource use?

OBJECTIVE: It remains unclear whether the "need" for care at a trauma center should be based on anatomic injury (the current standard) or specialized resource use. We investigated whether anatomic injury severity scores adequately explain hospital resource use. METHODS: This was a retrospective cohort study including children and adults meeting statewide trauma criteria and transported to 48 hospitals from 1998 to 2003. The injury severity score (ISS) was considered as both continuous (range 0-75) and categorical (0-8, 9-15, and >or= 16) terms. Specialized resource use was defined as: major surgery (with and without orthopedic intervention), mechanical ventilation > 96 hours, blood transfusion, intensive care unit (ICU) stay >or= 2 days, or in-hospital mortality. Resource use was assessed as both a binary variable and a continuous term. Descriptive statistics and simple and multivariable linear regressions were used to compare ISS and resource use. RESULTS: 33,699 injured persons were included in the analysis. Within mild, moderate, and serious anatomic injury categories, 8%, 26%, and 69%, respectively, had specialized resource use. When the resource use definition included orthopedic surgery, 12%, 49%, and 76%, respectively, had specialized resource use. Whereas there was fair correlation between ISS and additive resource use (rho = 0.61), ISS explained only 37% of the variability in resource use (adjusted R-squared = 0.37). Resource use within anatomic injury categories differed by age group. CONCLUSIONS: The standard anatomic injury criterion for trauma center "need" (i.e., ISS >or= 16) misclassifies a substantial number of injured persons requiring critical trauma resources. Out-of-hospital trauma triage guidelines based on anatomic injury may need revision to account for patients with resource need.