User-Guided Enhancements to a Technology-Facilitated Resilience Program to Address Opioid Risks Following Traumatic Injury in Youth: Qualitative Interview Study.

BACKGROUND: Youth with traumatic injury experience elevated risk for behavioral health disorders, yet posthospital monitoring of patients' behavioral health is rare. The Telehealth Resilience and Recovery Program (TRRP), a technology-facilitated and stepped access-to-care program initiated in hospitals and designed to be integrated seamlessly into trauma center operations, is a program that can potentially address this treatment gap. However, the TRRP was originally developed to address this gap for mental health recovery but not substance use. Given the high rates of substance and opioid use disorders among youth with traumatic injury, there is a need to monitor substance use and related symptoms alongside other mental health concerns. OBJECTIVE: This study aimed to use an iterative, user-guided approach to inform substance use adaptations to TRRP content and procedures. METHODS: We conducted individual semistructured interviews with adolescents (aged 12-17 years) and young adults (aged 18-25 years) who were recently discharged from trauma centers (n=20) and health care providers from two level 1 trauma centers (n=15). Interviews inquired about reactions to and recommendations for expanding TRRP content, features, and functionality; factors related to TRRP implementation and acceptability; and current strategies for monitoring patients' postinjury physical and emotional recovery and opioid and substance use. Interview responses were transcribed and analyzed using thematic analysis to guide new TRRP substance use content and procedures. RESULTS: Themes identified in interviews included gaps in care, task automation, user personalization, privacy concerns, and in-person preferences. Based on these results, a multimedia, web-based mobile education app was developed that included 8 discrete interactive education modules and 6 videos on opioid use disorder, and TRRP procedures were adapted to target opioid and other substance use disorder risk. Substance use adaptations included the development of a set of SMS text messaging-delivered questions that monitor both mental health symptoms and substance use and related symptoms (eg, pain and sleep) and the identification of validated mental health and substance use screening tools to monitor patients' behavioral health in the months after discharge. CONCLUSIONS: Patients and health care providers found the TRRP and its expansion to address substance use acceptable. This iterative, user-guided approach yielded novel content and procedures that will be evaluated in a future trial.

The Patient Experience of Adolescents With Traumatic Injuries: Recommendations for Improvement.

GOAL: Positive patient experience is associated with less healthcare utilization, better treatment adherence, increased likelihood of returning to the same hospital, and fewer complaints. However, hospitals have been able to collect few insights into the experiences of pediatric patients due to age limitations. As an exception to that reality, adolescents (aged 12-20 years) are able to share their experiences and recommend improvements, yet little is known about their hospital experiences with traumatic injuries. We examined the patient experience of adolescents with traumatic injuries and collected their recommendations for improving care. METHODS: We conducted 28 semistructured interviews with English-speaking adolescents hospitalized at two trauma Level 1 hospitals (pediatric and adult) for physical injuries from July 2018 to June 2021. Interviews were transcribed and analyzed using modified thematic analysis. PRINCIPAL FINDINGS: The patients expressed three basic desires: (1) autonomy and active involvement in their care, (2) human connections with their clinicians, and (3) minimal discomfort. Study participants provided actionable recommendations for improving the patient experience for adolescents with traumatic injuries. PRACTICAL APPLICATIONS: Hospital administrators and clinicians can improve the patient experience for adolescents in their care by sharing information, expectations, and goals with them. Hospital administrators can also empower the clinical staff to connect with adolescents with traumatic injuries on a personal level.

Pediatric cervical spine clearance: A 10-year evaluation of multidetector computed tomography at a level 1 pediatric trauma center.

INTRODUCTION: Efficient and accurate evaluation of the pediatric cervical spine (c-spine) for both injury identification and posttraumatic clearance remains a challenge. We aimed to determine the sensitivity of multidetector computed tomography (MDCT) for identification of cervical spine injuries (CSIs) in pediatric blunt trauma patients. METHODS: A retrospective cohort study was conducted at a level 1 pediatric trauma center from 2012 to 2021. All pediatric trauma patients age younger than 18 years who underwent c-spine imaging (plain radiograph, MDCT, and/or magnetic resonance imaging [MRI]) were included. All patients with abnormal MRIs but normal MDCTs were reviewed by a pediatric spine surgeon to assess specific injury characteristics. RESULTS: A total of 4,477 patients underwent c-spine imaging, and 60 (1.3%) were diagnosed with a clinically significant CSI that required surgery or a halo. These patients were older, more likely to be intubated, have a Glasgow Coma Scale score of <14, and more likely to be transferred in from a referring hospital. One patient with a fracture on radiography and neurologic symptoms got an MRI and no MDCT before operative repair. All other patients who underwent surgery including halo placement for a clinically significant CSI had their injury diagnosed by MDCT, representing a sensitivity of 100%. There were 17 patients with abnormal MRIs and normal MDCTs; none underwent surgery or halo placement. Imaging from these patients was reviewed by a pediatric spine surgeon, and no unstable injuries were identified. CONCLUSION: Multidetector computed tomography appears to have 100% sensitivity for detecting clinically significant CSIs in pediatric trauma patients, regardless of age or mental status. Forthcoming prospective data will be useful to confirm these results and inform recommendations for whether pediatric c-spine clearance can be safely performed based on the results of a normal MDCT alone. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level IV.

Hanging and Strangulation Injuries: An Institutional Review From a Level 1 Pediatric Trauma Center.

BACKGROUND: We sought to define the incidence and outcomes of pediatric hanging and strangulation injuries to inform best practices for trauma triage and management. METHODS: A retrospective review was conducted that included all patients who presented after hanging or strangulation to a Level I Pediatric Trauma Center from 2011 through 2021. Patient demographics, injury characteristics, and clinical outcomes were collected. All imaging modalities of the head and neck were reviewed to determine if a bony fracture or vascular injury was present. RESULTS: Over the 11-year study period, 128 patients met inclusion criteria. The median age of the cohort was 13 years [IQR: 8.5-15], most patients were male (60.9%), and the median GCS was 11 [3, 15]. There were 96 cases (75%) that were intentional injuries. 76 patients (59.4%) received imaging in the form of plain radiographs, CT, or MRI of the neck and cervical spine. No fractures were identified and there were 0 clinically significant cervical spine injuries. CT angiograms of the neck identified no cerebral vascular injuries. Mortality was high (32%), and 25% of patients with nonaccidental injuries had a documented prior suicide attempt. CONCLUSION: We identified no cervical spine fractures and no blunt cerebral vascular injuries after a hanging or strangulation in over 10 years at a Level 1 Pediatric Trauma Center. Use of CT and CT angiography of the neck and cervical spine should be minimized in this patient population without high clinical index of suspicion and/or significant mechanism. LEVEL OF EVIDENCE: IV.

Using prescription opioids throughout a traumatic injury recovery: A qualitative exploratory study of adolescents in a Midwestern state.

BACKGROUND: Injury is one of the most common reasons adolescents are prescribed opioids. Little is known about adolescent experiences who used prescription opioids throughout their recovery from traumatic injury. METHODS: We used a qualitative exploratory study design nested within a longitudinal cohort study conducted at two trauma hospitals in the United States. We conducted semi-structured telephone interviews with adolescents (n = 28) aged from 12 to 20 years at the time of their hospital admission for injury. We used purposive sampling to gather a broad range of experiences from the longitudinal patient cohort. We conducted a modified thematic analysis of transcribed interviews. RESULTS: Adolescents reported a wide range of efficacy with which prescription opioids controlled their pain during the injury recovery and numerous opioid-related side effects. A desire for relief from acute pain caused by the injury was the most common driver for using opioids in the hospital. At home, adolescents' decisions to use opioids were influenced by family history of addiction, awareness of harms associated with opioids, and desire to challenge themselves. Adolescents reported closely adhering to a prescribed regimen or using fewer opioids than prescribed while recovering at home. Finally, adolescents reported considerable variability in parental involvement in prescription opioid use, ranging from giving adolescents unrestricted access to prescription opioids to complete parental discretion and administration upon request. CONCLUSIONS: Adolescents had diverse experiences with prescription opioids during recovery from traumatic injury. Educational interventions that focus on the appropriate use of opioids to address pain care needs among adolescents with traumatic injuries are urgently needed.

Outpatient Opioid Prescriptions are Associated With Future Substance Use Disorders and Overdose Following Adolescent Trauma.

OBJECTIVE: This study aims to determine if outpatient opioid prescriptions are associated with future SUD diagnoses and overdose in injured adolescents 5 years following hospital discharge. SUMMARY OF BACKGROUND DATA: Approximately, 1 in 8 adolescents are diagnosed with an SUD and 1 in 10 experience an overdose in the 5 years following injury. State laws have become more restrictive on opioid prescribing by acute care providers for treating pain, however, prescriptions from other outpatient providers are still often obtained. METHODS: This was a retrospective cohort study of patients ages 12-18 admitted to 2 level I trauma centers. Demographic and clinical data contained in trauma registries were linked to a regional database containing 5 years of electronic health records and prescription data. Regression models assessed whether number of outpatient opioid prescription fills after discharge at different time points in recovery were associated with a new SUD diagnosis or overdose, while controlling for demographic and injury characteristics, and depression and posttraumatic stress disorder diagnoses. RESULTS: We linked 669 patients (90.9%) from trauma registries to a regional health information exchange database. Each prescription opioid refill in the first 3 months after discharge increased the likelihood of new SUD diagnoses by 55% (odds ratio: 1.55, confidence interval: 1.04-2.32). Odds of overdose increased with ongoing opioid use over 2-4 years post-discharge ( P = 0.016-0.025). CONCLUSIONS: Short-term outpatient opioid prescribing over the first few months of recovery had the largest effect on developing an SUD, while long-term prescription use over multiple years was associated with a future overdose.

Perceived loss of social support after non-neurologic injury negatively impacts recovery.

BACKGROUND: Traumatic injury is not only physically devastating, but also psychologically isolating, potentially leading to poor quality of life, depression and posttraumatic stress disorder (PTSD). Perceived social support (PSS) is associated with better outcomes in some populations. What is not known is if changes in PSS influence long-term outcomes following nonneurologic injury. We hypothesized that a single drop in PSS during recovery would be associated with worse quality of life. METHODS: This is a post hoc analysis of a prospectively collected database that included patients 18 years or older admitted to a Level I trauma center with Injury Severity Score (ISS) of 10 or higher, and no traumatic brain or spinal cord injury. Demographic and injury data were collected at the initial hospital admission. Screening for depression, PTSD, and Medical Outcomes Study Short Form 36 Mental Composite Score (MCS) were obtained at the initial hospitalization, 1, 2, 4, and 12 months postinjury. The Multidimensional Scale of Perceived Social Support (MSPSS) was obtained at similar time points. Patients with high MSPSS (>5) at baseline were included and grouped by those that ever reported a score ≤5 (DROP), and those that remained high (STABLE). Outcomes were determined at 4 and 12 months. RESULTS: Four hundred eleven patients were included with 96 meeting DROP criteria at 4 months, and 97 at 1 years. There were no differences in sex, race, or injury mechanism. The DROP patients were more likely to be single (p = 0.012 at 4 months, p = 0.0006 at 1 year) and unemployed (p = 0.016 at 4 months, and p = 0.026 at 1 year) compared with STABLE patients. At 4 months and 1 year, DROP patients were more likely to have PTSD, depression, and a lower MCS (p = 0.0006, p < 0.0001). CONCLUSION: Patients who have a drop in PSS during the first year of recovery have significantly higher odds of poor psychological outcomes. Identifying these socially frail patients provides an opportunity for intervention to positively influence an otherwise poor quality of life. LEVEL OF EVIDENCE: Therapeutic, Prognostic and Epidemiological, Level III.

National Instant Criminal Background Check and Youth Gun Carrying.

BACKGROUND: Despite being unable to purchase firearms directly, many adolescents have access to guns, leading to increased risk of injury and death. We sought to determine if the National Instant Criminal Background Check System (NICS) changed adolescents' gun-carrying behavior. METHODS: We performed a repeated cross-sectional study using National Youth Risk Behavior Survey data from years 1993 to 2017. We used a survey-weighted multivariable logistic regression model to determine if the NICS had an effect on adolescent gun carrying, controlling for state respondent characteristics, state laws, state characteristics, the interaction between the NICS and state gun laws, and time. RESULTS: On average, 5.8% of the cohort reported carrying a gun. Approximately 17% of respondents who carried guns were from states with a universal background check (U/BC) provision at the point of sale, whereas 83% were from states that did not have such laws (P < .001). The model indicated that the NICS together with U/BCs significantly reduced gun carrying by 25% (adjusted relative risk = 0.75 [95% confidence interval: 0.566-0.995]; P = .046), whereas the NICS independently did not (P = .516). CONCLUSIONS: Adolescents in states that require U/BCs on all prospective gun buyers are less likely to carry guns compared with those in states that only require background checks on sales through federally licensed firearms dealers. The NICS was only effective in reducing adolescent gun carrying in the presence of state laws requiring U/BCs on all prospective gun buyers. However, state U/BC laws had no effect on adolescent gun carrying until after the NICS was implemented.

Long-term prescription opioid utilization, substance use disorders, and opioid overdoses after adolescent trauma.

BACKGROUND: Injured adolescents have a 56% increased risk of developing a substance use disorder (SUD) within 3 years of their injury. The transition from medical prescription opioid use to nonmedical use in adolescent trauma patients has not been longitudinally studied long-term. The aim of this study is to describe 5-year patterns of opioid use in a cohort of injured adolescents as well as the proportion of patients experiencing overdose and SUD diagnoses. METHODS: Our retrospective cohort study consisted of 736 patients aged 12 years to 18 years who were admitted for trauma from 2011 to 2013. We examined up to 5 years of regional health information exchange data containing information on prescription fills as well as diagnoses from inpatient, outpatient, and emergency department encounters. RESULTS: At 1 year, over 20% of adolescents filled more than two opioid prescriptions after being discharged for their injury; and at 4 years, over 13% had received more than eight opioid fills. Over the 5-year period, 11% received an opioid antagonist injection, 14% received an SUD diagnosis, and 8% had an overdose diagnosis. Relatively few patients had diagnoses for other mental health conditions including depression (5.5%), posttraumatic stress disorder (2.1%), and chronic pain (3.6%). CONCLUSION: Opioid usage remains high for multiple years in a subset of the adolescent trauma population. Mental health diagnosis rates were substantially lower in injured adolescents than what has been reported in adults. However, overdose and SUD diagnoses occur in over 1 in 10 adolescents within 5 years of their injury. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level IV.

The conference effect: National surgery meetings are associated with increased mortality at trauma centers without American College of Surgeons verification.

BACKGROUND: Thousands of physicians attend scientific conferences each year. While recent data indicate that variation in staffing during such meetings impacts survival of non-surgical patients, the association between treatment during conferences and outcomes of a surgical population remain unknown. The purpose of this study was to examine mortality resulting from traumatic injuries and the influence of hospital admission during national surgery meetings. STUDY DESIGN: Retrospective analysis of in-hospital mortality using data from the Trauma Quality Improvement Program (2010-2011). Identified patients admitted during four annual meetings and compared their mortality with that of patients admitted during non-conference periods. Analysis included 155 hospitals with 12,256 patients admitted on 42 conference days and 82,399 patients admitted on 270 non-conference days. Multivariate analysis performed separately for hospitals with different levels of trauma center verification by state and American College of Surgeons (ACS) criteria. RESULTS: Patient characteristics were similar between meeting and non-meeting dates. At ACS level I and level II trauma centers during conference versus non-conference dates, adjusted mortality was not significantly different. However, adjusted mortality increased significantly for patients admitted to trauma centers that lacked ACS trauma verification during conferences versus non-conference days (OR 1.2, p = 0.008), particularly for patients with penetrating injuries, whose mortality rose from 11.6% to 15.9% (p = 0.006). CONCLUSIONS: Trauma mortality increased during surgery conferences compared to non-conference dates for patients admitted to hospitals that lacked ACS trauma level verification. The mortality difference at those hospitals was greatest for patients who presented with penetrating injuries.

National Cancer Institute Centers and Society of Surgical Oncology Cancer Research Synergy.

BACKGROUND: The objective of this study was to examine the influence of Surgical Society Oncology (SSO) membership and National Cancer Institute (NCI) status on the academic output of surgical faculty. METHODS: NCI cancer program status for each department of surgery was identified with publically available data, whereas SSO membership was determined for every faculty member. Academic output measures such as NIH funding, publications, and citations were analyzed in subsets by the type of cancer center (NCI comprehensive cancer center [CCC]; NCI cancer center [NCICC]; and non-NCI center) and SSO membership status. RESULTS: Of the surgical faculty, 2537 surgeons (61.9%) were from CCC, whereas 854 (20.8%) were from NCICC. At the CCC, 22.7% of surgeons had a history of or current NIH funding, compared with 15.8% at the NCICC and 11.8% at the non-NCI centers. The academic output of SSO members was higher at NCICC (52 ± 113 publications/1266 ± 3830 citations) and CCC (53 ± 92/1295 ± 4001) compared with nonmembers (NCICC: 26 ± 78/437 ± 2109; CCC: 37 ± 91/670 ± 3260), respectively, P < 0.05. Multivariate logistic regression revealed that SSO membership imparts an additional 22 publications and 270 citations, whereas NCI-designated CCC added 10 additional publications, but not citations. CONCLUSIONS: CCCs have significantly higher academic output and NIH funding. Recruitment of SSO members, a focus on higher performing divisions, and NIH funding are factors that non-NCI cancer centers may be able to focus on to improve academic productivity to aid in obtaining NCI designation.

Assessing outpatient follow-up care compliance, complications, and sequelae in children hospitalized for isolated traumatic abdominal injuries.

BACKGROUND: Currently there is limited knowledge on compliance with follow-up care in pediatric patients after abdominal trauma. The Indiana Network for Patient Care (INPC) is a large regional health information exchange with both structured clinical data (e.g., diagnosis codes) and unstructured data (e.g., provider notes). The objective of this study is to determine if regional health information exchanges can be used to evaluate whether patients receive all follow-up care recommended by providers. METHODS: We identified 61 patients treated at a Pediatric Level I Trauma Center who were admitted for isolated abdominal injuries. We analyzed medical records for two years following initial hospital discharge for injury using the INPC. The encounters were classified by the type of encounter: outpatient, emergency department, unplanned readmission, surgery, imaging studies, and inpatient admission; then further categorized into injury- and non-injury-related care, based on provider notes. We determined compliance with follow-up care instructions given at discharge and subsequent outpatient visits, as well as the prevalence of complications and sequelae. RESULTS: After reviewing patient records, we found that 78.7% of patients received all recommended follow-up care, 6.6% received partial follow-up care, and 11.5% did not receive follow-up care. We found that 4.9% of patients developed complications after abdominal trauma and 9.8% developed sequelae in the two years following their initial hospitalization. CONCLUSIONS: Our findings suggest that health information exchanges such as the INPC are useful in evaluation of follow-up care compliance and prevalence of complications/sequelae after abdominal trauma in pediatric patients. LEVEL OF EVIDENCE: Level IV.

Three cachexia phenotypes and the impact of fat-only loss on survival in FOLFIRINOX therapy for pancreatic cancer.

BACKGROUND: By the traditional definition of unintended weight loss, cachexia develops in ~80% of patients with pancreatic ductal adenocarcinoma (PDAC). Here, we measure the longitudinal body composition changes in patients with advanced PDAC undergoing 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin therapy. METHODS: We performed a retrospective review of 53 patients with advanced PDAC on 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin as first line therapy at Indiana University Hospital from July 2010 to August 2015. Demographic, clinical, and survival data were collected. Body composition measurement by computed tomography (CT), trend, univariate, and multivariate analysis were performed. RESULTS: Among all patients, three cachexia phenotypes were identified. The majority of patients, 64%, had Muscle and Fat Wasting (MFW), while 17% had Fat-Only Wasting (FW) and 19% had No Wasting (NW). NW had significantly improved overall median survival (OMS) of 22.6 months vs. 13.0 months for FW and 12.2 months for MFW (P = 0.02). FW (HR = 5.2; 95% confidence interval = 1.5-17.3) and MFW (HR = 1.8; 95% confidence interval = 1.1-2.9) were associated with an increased risk of mortality compared with NW. OMS and risk of mortality did not differ between FW and MFW. Progression of disease, sarcopenic obesity at diagnosis, and primary tail tumours were also associated with decreased OMS. On multivariate analysis, cachexia phenotype and chemotherapy response were independently associated with survival. Notably, CT-based body composition analysis detected tissue loss of >5% in 81% of patients, while the traditional definition of >5% body weight loss identified 56.6%. CONCLUSIONS: Distinct cachexia phenotypes were observed in this homogeneous population of patients with equivalent stage, diagnosis, and first-line treatment. This suggests cellular, molecular, or genetic heterogeneity of host or tumour. Survival among patients with FW was as poor as for MFW, indicating adipose tissue plays a crucial role in cachexia and PDAC mortality. Adipose tissue should be studied for its mechanistic contributions to cachexia.

Prevalence and treatment of depression and posttraumatic stress disorder among trauma patients with non-neurological injuries.

BACKGROUND: Psychological impairment among injury survivors is well documented. Little is known about the prevalence of treatment of psychological impairment, however. We aimed to determine the proportion of injury survivors treated for depression and posttraumatic stress disorder (PTSD) in the year after injury as well as to determine potential barriers to treatment. METHODS: Adults (18 and older) admitted to a Level I trauma center with an injury severity score greater than 10 but without traumatic brain injury or spinal cord injury were eligible for study inclusion. The Center for Epidemiological Studies-Depression and PTSD CheckList-Civilian Versions surveys were administered during the initial hospitalization and repeated at 1, 2, 4, and 12 months after injury. Patients were asked if they received treatment specifically for depression or PTSD at each follow-up. Factors associated with treatment were determined using multivariable logistic regression analysis. RESULTS: Five hundred injury survivors were enrolled in this prospective observational study. Of those, 68.4% of patients screened positive for depression at some point in the year after their injury (53.3%, 1 month; 49.9%, 2 months; 49.0%, 4 months; and 50.2%, 12 months). Only 22.2% of depressed patients reported receiving treatment for depression; 44.4% of patients screened positive for PTSD (26.6%, 1 month; 27.8%, 2 months; 29.8%, 4 months; and 30.0%, 12 months), but only 9.8% received treatment for PTSD. After adjusting for other factors, compared to commercial insurance status, self-pay insurance status was negatively associated with treatment for PTSD or depression (odds ratio, 0.44; 95% confidence interval, 0.21-0.95). CONCLUSION: Depression and PTSD are common in non-neurotrauma patients in the year following injury. Greater collaboration between those caring for injury survivors and behavioral health experts may help improve psychological outcomes after injury. LEVEL OF EVIDENCE: Therapeutic/Care management, level IV.

Accounting for early job turnover in recent pediatric surgery fellowship graduates: An American Pediatric Surgical Association Membership and Credentials Committee study.

PURPOSE: Employment opportunities for graduating pediatric surgeons vary from year to year. Significant turnover among new employees indicates fellowship graduates may be unsophisticated in choosing job opportunities which will ultimately be satisfactory for themselves and their families. The purpose of this study was to assess what career, life, and social factors contributed to the turnover rates among pediatric surgeons in their first employment position. METHODS: American Pediatric Surgical Association members who completed fellowship training between 2011 and 2016 were surveyed voluntarily. Only those who completed training in a pediatric surgery fellowship sanctioned by the American Board of Surgery and whose first employment involved the direct surgical care of patients were included. The survey was completed electronically and the results were evaluated using chi-squared analysis to determine which independent variables contributed to a dependent outcome of changing place of employment. RESULTS: 110 surveys were returned with respondents meeting inclusion criteria. 13 (11.8%) of the respondents changed jobs within the study period and 97 (88.2%) did not change jobs. Factors identified that likely contributed to changing jobs included a perceived lack of opportunity for career [p = <0.001] advancement and the desire to no longer work at an academic or teaching facility [p = 0.013]. Others factors included excessive case load [p = 0.006]; personal conflict with partners or staff [p = 0.007]; career goals unfulfilled by practice [p = 0.011]; lack of mentorship in partners [p = 0.026]; and desire to be closer to the surgeon's or their spouse's family [p = 0.002]. CONCLUSIONS: Several factors appear to play a role in motivating young pediatric surgeons to change jobs early in their careers. These factors should be taken into account by senior pediatric fellows and their advisors when considering job opportunities. TYPE OF STUDY: Survey. LEVEL OF EVIDENCE: IV.

Shock volume: Patient-specific cumulative hypoperfusion predicts organ dysfunction in a prospective cohort of multiply injured patients.

BACKGROUND: Multiply injured patients are at risk of developing hemorrhagic shock and organ dysfunction. We determined how cumulative hypoperfusion predicted organ dysfunction by integrating serial Shock Index measurements. METHODS: In this study, we calculated shock volume (SHVL) which is a patient-specific index that quantifies cumulative hypoperfusion by integrating abnormally elevated Shock Index (heart rate/systolic blood pressure ≥ 0.9) values acutely after injury. Shock volume was calculated at three hours (3 hr), six hours (6 hr), and twenty-four hours (24 hr) after injury. Organ dysfunction was quantified using Marshall Organ Dysfunction Scores averaged from days 2 through 5 after injury (aMODSD2-D5). Logistic regression was used to determine correspondence of 3hrSHVL, 6hrSHVL, and 24hrSHVL to organ dysfunction. We compared correspondence of SHVL to organ dysfunction with traditional indices of shock including the initial base deficit (BD) and the lowest pH measurement made in the first 24 hr after injury (minimum pH). RESULTS: SHVL at all three time intervals demonstrated higher correspondence to organ dysfunction (R = 0.48 to 0.52) compared to initial BD (R = 0.32) and minimum pH (R = 0.32). Additionally, we compared predictive capabilities of SHVL, initial BD and minimum pH to identify patients at risk of developing high-magnitude organ dysfunction by constructing receiver operator characteristic curves. SHVL at six hours and 24 hours had higher area under the curve compared to initial BD and minimum pH. CONCLUSION: SHVL is a non-invasive metric that can predict anticipated organ dysfunction and identify patients at risk for high-magnitude organ dysfunction after injury. LEVEL OF EVIDENCE: Prognostic study, level III.

Sarcopenia is a Significant Predictor of Mortality After Abdominal Aortic Aneurysm Repair.

AIMS: Repair of abdominal aortic aneurysms (AAA) decreases the incidence of rupture and death. In cancer patients, sarcopenia has been associated with increased surgical complications and mortality. The impact of sarcopenia on survival after AAA repair has yet to be described. METHODS AND RESULTS: Patient demographic, laboratory, body composition measurements and survival data were obtained from patients undergoing AAA repair at the Indiana University medical campus over a 5-year period. Univariate and multivariate analyses were performed to identify factors associated with overall survival. Overall, 58.2% presented with sarcopenia. Sarcopenic patients were older (71.8±8.3 versus 66.8±8.1 years; p<0.001), had lower body mass index (BMI) (26.3±5.2 versus 31.5±5.9 kg/m2; p<0.001), higher rates of myosteatosis (84.4% versus 52.%; p<0.001), greater AAA diameter (60.6±14.0 versus 57.8±11.7 mm; p=0.016), higher Charlson Comorbidity Index (CCI) (32.3% versus 25.1% ≥6; p=0.034), and increased rates of rupture (8.2% versus 3.8%; p=0.047). Sarcopenic and nonsarcopenic patients had no difference in 30-day morbidity (8.5% versus 8.5%; p=0.991) or mortality (3.7% versus 0.9%; p=0.07). Univariate analysis demonstrated age, sarcopenia, myosteatosis, CCI, and BMI to be associated with long-term survival. There was no correlation between BMI and sarcopenia. Both sarcopenia and myosteatosis resulted in decreased one-, three-, and five-year survivals compared to their counterparts. On multivariate analysis sarcopenia is independently associated with survival, conferring a 1.6-fold increase in death (p=0.04). The combination of sarcopenia plus myosteatosis doubled the risk of death compared to sarcopenia alone. CONCLUSIONS: This is the first study to demonstrate that over half of all patients undergoing AAA repair are sarcopenic, a condition associated with increased mortality. Sarcopenia with myosteatosis is associated with double the mortality of sarcopenia alone. CT scan, but not BMI, accurately identifies sarcopenia and myosteatosis. Defining the mechanisms through which sarcopenia contributes to late death after AAA repair is critical to developing novel interventions that may improve survival in this high risk population.

Long-term evaluation of a hospital-based violence intervention program using a regional health information exchange.

BACKGROUND: Hospital-based violence intervention programs (HVIP) aim to reduce violent-injury recidivism by providing intensive case management services to high-risk patients who were violently injured. Although HVIP have been found effective at reducing recidivism, few studies have sought to identity how long their effects last. Additionally, prior studies have been limited by the fact that HVIP typically rely on self-report or data within their own healthcare system to identify new injuries. Our aim was to quantify the long-term recidivism rate of participants in an HVIP program using more objective and comprehensive data from a regional health information exchange. METHODS: The study included 328 patients enrolled in Prescription for Hope (RxH), an HVIP, between January 2009 and August 2016. We obtained RxH participants' emergency department (ED) encounter data from a regional health information exchange database from the date of hospital discharge to February 2017. Our primary outcome was violent-injury recidivism rate of the RxH program. We also examined reasons for ED visits that were unrelated to violent injury. RESULTS: We calculated a 4.4% recidivism rate based on 8 years of statewide data, containing 1,575 unique encounters. More than 96% of participants were matched in the state database. Of the 15 patients who recidivated, only five were admitted for their injury. More than half of new violence-related injuries were treated outside of the HVIP-affiliated trauma center. The most common reasons for ED visits were pain (718 encounters), followed by suspected complications or needing additional postoperative care (181 encounters). Substance abuse, unintentional injuries, and suicidal ideation were also frequent reasons for ED visits. CONCLUSION: The low, long-term recidivism rate for RxH indicates that HVIPs have enduring positive effects on the majority of participants. Our results suggest that HVIP may further benefit patients by partnering with organizations that work to prevent suicide, substance use disorders, and other unintentional injuries. LEVEL OF EVIDENCE: Therapeutic study, level III.