Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study.

Background: Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA. Methods: The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury. Results: 14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%. Conclusion: The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage. Level of evidence: 2.

Bone Anchor Fixation in the Repair of Blunt Traumatic Abdominal Wall Hernias: A Western Trauma Association Multicenter Study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair. METHODS: A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses. RESULTS: 176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts. CONCLUSIONS: This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life.

Predictive Factors for the Application of Pelvic Binders in the Prehospital Setting.

OBJECTIVES: Early pelvic binder placement in the field stabilizes pelvic fractures and tamponades potential hemorrhage within the pelvis. Despite known risk factors for pelvic fracture, it remains challenging to quickly triage and correctly apply a pelvic binder. We aim to develop a prediction model that exclusively uses prehospital criteria to inform the decision to place a pelvic binder. METHODS: The trauma registry was used to identify all trauma patients admitted to an urban Level I trauma center between January 2013 and December 2017. Variables collected included patient demographics, mechanism of injury, prehospital vital signs, and the presence of a pelvic fracture. Participants were randomly assigned to a training group (70%) or a validation group (30%). Univariate analyses were used to identify significant predictors for use in multivariate predictive models. RESULTS: A total of 8,480 (65% male; median age 49; median ISS 9) and 3,676 (65% male; median age 48; median ISS 9) trauma patients were randomly assigned to the training and validation groups, respectively. Univariate analysis showed significant likelihood of pelvic fracture associated with female sex, hemodynamic instability (initial systolic blood pressure < 90 mmHg), blunt injury type, specific mechanisms of injury (motor vehicle collision, motorcycle collision, pedestrian struck by motor vehicle, crushing injury, and riding an animal), impact location, and position in vehicle. Multivariate models adjusting for blunt type injury, hemodynamic instability, impact location, and position in vehicle showed that presence of two or more of these risk factors is significantly associated with presence of pelvic fracture. CONCLUSION: Establishing select prehospital criteria for the empiric application of pelvic binders for patients in the field with blunt injuries, hemodynamic instability, frontal or side motor vehicle collision impact, and non-front seat passenger may improve outcomes among patients with pelvic fractures.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study.

BACKGROUND: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Optimizing discharge opioid prescribing in trauma patients: A quasi-experimental study.

BACKGROUND: Patients prescribed higher opioid dosages are at increased risk of overdose and death without added pain reduction. Increases in opioid prescribing continue to fuel the epidemic. We hypothesized a comprehensive guideline to standardize opioid prescribing would decrease postdischarge dosages for patients experiencing trauma without requiring additional refills. METHODS: This quasiexperimental study compared opioid prescribing by trauma providers before and after the implementation of a departmental guideline on April 1, 2019, aimed at aligning opioid prescription patterns with Centers for Disease Control and Prevention recommendations. Patients prescribed opioids before implementation were the control group, whereas patients prescribed opioids after were the intervention group. The primary outcome was the proportion of patients receiving ≥50 morphine milligram equivalents per day. RESULTS: We identified 293 and 280 patients experiencing trauma in the control and intervention groups, respectively. There were no differences between the groups' Injury Severity Score (P = .69) or the frequency of having a procedure performed (P = .80). Total morphine milligram equivalents and maximum morphine milligram equivalents per day were 16% and 25% lower, respectively, in the intervention group compared with the control group (P < .001). The proportion of trauma patients prescribed ≥50 morphine milligram equivalents per day at discharge decreased from 57% to 18% after implementation (P < .001). The proportion of trauma patients prescribed ≥90 morphine milligram equivalents per day also decreased, from 37% to 14% (P < .001). There was no significant increase in the frequency of refill requests (P = .105) or refill prescriptions (P = .099) after discharge. CONCLUSION: A departmental guideline aimed at optimizing opioid prescription patterns successfully lowers the amount of morphine milligram equivalents prescribed to trauma patients and improves compliance with Centers for Disease Control and Prevention recommendations.

Mechanical Ventilation Does Not Predict Pneumothorax Observation Failure in the Severely Injured.

BACKGROUND: Observative management of small traumatic pneumothoraces (PTX) has been shown to decrease chest tube utilization in non-mechanically ventilated patients without compromising outcomes. This approach could be used in mechanically ventilated (MV) patients, though many feel these patients are at increased risk of observation failure. METHODS: A single center retrospective study of all adults undergoing observation of a computed tomography (CT) diagnosed PTX from 2015-2019. Patients with chest tube placement within 4-hours of arrival, concurrent hemothorax, or death within 24-hours were excluded. Observation failure was defined as chest tube placement. RESULTS: Of 340 patients, 64 were on MV. The groups were of similar age, BMI, underlying pulmonary comorbidities, and PTX size (10.1 mm vs 8.8 mm, P = .20). The MV group was more severely injured (ISS [25+] [60.9% vs 11.2%, P < .001]). There was no difference in observation failure rates by MV status overall (6.3% vs 5.1%, P = .75) or by PTX size (<15 mm [5% vs 2.2%, P = .37], <20 mm [4.8% vs 3.1%, P = .45], <25 mm [4.8% vs 4.1%, P = .73], <30 mm [4.8% vs 4.1%, P = .73], <35 mm [4.8% vs 4.7%, P = 1.00]). MV was not an independent predictor of observation failure on multivariable analysis (OR .64, 95% CI .18-2.20), though PTX size was (OR 1.11, 95% CI 1.05-1.17). When comparing those who failed vs those who did not, the only difference was PTX size (9.34 mm vs 19.41 mm, P < .001). CONCLUSION: MV is not an independent predictor of PTX observation failure. While PTX size appears to play a role, further studies are needed to outline safe parameters for observation in those undergoing MV.

Predicting outcomes after traumatic brain injury: A novel hospital prediction model for a patient reported outcome.

BACKGROUND: Estimation of long-term quality of life in patients sustaining Traumatic brain injuries is a difficult but important task during the early hospitalization. There are very limited tools to assess these outcomes, therefore we aimed to develop a predictive model for quality-of-life that could be used in hospitalized adults with TBIs. METHODS: The TRACK-TBI dataset was used to identify adult patients with TBI from 2014 to 2018. Multiple variables were assessed to predict favorable versus unfavorable scores on the Quality of Life after Brain Injury-Overall Scale (QOLIBRI-OS). RESULTS: We included 1549 subjects. 57% had a favorable outcome, and were more likely to have private insurance, higher GCS scores, and fewer comorbidities. A model (TBI-PRO) for 3, 6, and 12-month QOLIBRI score was created. The AUROCs for predicting 3, 6 and 12-month favorable QOLIBRI scores were 0.81, 0.79, and 0.76, respectively. CONCLUSION: The TBI-PRO model adequately estimates long-term outcomes in patients with TBI.

The 35-mm rule to guide pneumothorax management: Increases appropriate observation and decreases unnecessary chest tubes.

INTRODUCTION: Axial imaging has allowed for more precise measurement and, in-turn, more objective guidelines related to the management of traumatic pneumothoraces (PTXs). In 2017, our trauma center used a guideline to observe any PTX ≤35 mm in stable patients. We hypothesize that this guideline would decrease unnecessary chest tubes without affecting failure rates. METHODS: This is a single-center retrospective review of all adult trauma patients who had a PTX diagnosed on computed tomography before (2015-2016) and after (2018-2019) guideline implementation. We excluded patients with chest tubes inserted before computed tomography, concurrent hemothoraces, mechanical ventilation, or mortality in the first 24 hours. Descriptive statistical analyses, χ2 test, and Mann-Whitney U test were performed as appropriate. RESULTS: A total of 266 patients met our inclusion criteria. Ninety-nine (37.2%) and 167 patients (62.7%) were admitted before and after 2017, respectively. Overall, there were no differences in demographics or severity of injuries between both groups. After guideline implementation, there was a significant increase in observation rates and compliance rate. Tube thoracostomies decreased from 28.3% to 18% (p = 0.04). There were no statistically significant changes in observation failure rates, hospital or intensive care unit length of stay, complications, or mortality. CONCLUSION: The implementation of the 35 mm guideline is an effective tool to decrease unnecessary tube thoracostomy in hemodynamically normal patients without evidence of hemothorax. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Trauma surgeon-performed peripheral arterial repairs are associated with equivalent outcomes when compared with vascular surgeons.

BACKGROUND: Civilian extremity trauma with vascular injury carries a significant risk of morbidity, limb loss, and mortality. We aim to describe the trends in extremity vascular injury repair and compare outcomes between trauma and vascular surgeons. METHODS: We performed a single-center retrospective review of patients 18 years or older with extremity vascular injury requiring surgical intervention between January 2009 and December 2019. Demographics, injury characteristics, operative course, and hospital course were analyzed. Descriptive statistics were used to examine management trends, and outcomes were compared for arterial repairs. Multivariate regression was used to evaluate surgeon specialty as a predictor of complications, readmission, vascular outcomes, and mortality. RESULTS: A total of 231 patients met our inclusion criteria; 80% were male with a median age of 29 years. The femoral vessels were most commonly injured (39.4%), followed by the popliteal vessels (26.8%). Trauma surgeons performed the majority of femoral artery repairs (82%), while vascular surgeons repaired the majority of popliteal artery injuries (84%). Both had a similar share of brachial artery repairs (36% vs. 39%, respectively). There were no differences in complications, readmission, vascular outcomes, and mortality. Median time from arrival to operating room was significantly shorter for trauma surgeons. There was a significant downward trend between 2009 and 2017 in the proportion of total and femoral vascular procedures performed by trauma surgeons. On multivariate regression, surgical specialty was not a significant predictor of need for vascular reintervention, prophylactic or delayed fasciotomies, postoperative complications, or readmissions. CONCLUSION: Traumas surgeons arrived quicker to the operating and had no difference in short-term clinical outcomes of brachial and femoral artery repairs compared with patients treated by vascular surgeons. Over the last decade, there has been a significant decline in the number of open vascular repairs done by trauma surgeons. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

Improving mortality in older adult trauma patients: Are we doing better?

BACKGROUND: Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care. MATERIALS AND METHODS: This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality. RESULTS: There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p > 0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49). CONCLUSION: Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

Optimal timing of venous thromboembolic chemoprophylaxis initiation following blunt solid organ injury: meta-analysis and systematic review.

PURPOSE: The need to prevent venous thromboembolism (VTE) following blunt solid organ injury must be balanced against the concern for exacerbation of hemorrhage. The optimal timing for initiation of VTE chemoprophylaxis is not known. The objective was to determine the safety and efficacy of early (≤ 48 h) VTE chemoprophylaxis initiation following blunt solid organ injury. METHODS: An electronic search was performed of medical libraries for English language studies on timing of VTE chemoprophylaxis initiation following blunt solid organ injury published from inception to April 2020. Included studies compared early (≤ 48 h) versus late (> 48 h) initiation of VTE chemoprophylaxis in adults with blunt splenic, liver, and/or kidney injury. Estimates were pooled using random-effects meta-analysis. Odds ratios were utilized to quantify differences in failure of nonoperative management, need for blood transfusion and rates of VTE. RESULTS: The search identified 2,111 studies. Of these, ten studies comprising 14,675 patients were included. All studies were non-randomized and only one was prospective. The overall odds of failure of nonoperative management were no different between early and late groups, OR 1.09 (95%CI 0.92-1.29). Similarly, there was no difference in the need for blood transfusion either during overall hospital stay, OR 0.91 (95%CI 0.70-1.18), or post prophylaxis initiation, OR 1.23 (95%CI 0.55-2.73). There were significantly lower odds of VTE when patients received early VTE chemoprophylaxis, OR 0.51 (95%CI 0.33-0.81). CONCLUSIONS: Patients undergoing nonoperative management for blunt solid organ injury can be safely and effectively prescribed early VTE chemoprophylaxis. This results in significantly lower VTE rates without demonstrable harm.

Need for Emergent Intervention within 6 Hours: A Novel Prediction Model for Hospital Trauma Triage.

Objective: A tiered trauma team activation system allocates resources proportional to patients' needs based upon injury burden. Previous trauma hospital-triage models are limited to predicting Injury Severity Score which is based on > 10% all-cause in-hospital mortality, rather than need for emergent intervention within 6 hours (NEI-6). Our aim was to develop a novel prediction model for hospital-triage that utilizes criteria available to the EMS provider to predict NEI-6 and the need for a trauma team activation.Methods: A regional trauma quality collaborative was used to identify all trauma patients ≥ 16 years from the American College of Surgeons-Committee on Trauma verified Level 1 and 2 trauma centers. Logistic regression and random forest were used to construct two predictive models for NEI-6 based on clinically relevant variables. Restricted cubic splines were used to model nonlinear predictors. The accuracy of the prediction model was assessed in terms of discrimination.Results: Using data from 12,624 patients for the training dataset (62.6% male; median age 61 years; median ISS 9) and 9,445 patients for the validation dataset (62.6% male; median age 59 years; median ISS 9), the following significant predictors were selected for the prediction models: age, gender, field GCS, vital signs, intentionality, and mechanism of injury. The final boosted tree model showed an AUC of 0.85 in the validation cohort for predicting NEI-6.Conclusions: The NEI-6 trauma triage prediction model used prehospital metrics to predict need for highest level of trauma activation. Prehospital prediction of major trauma may reduce undertriage mortality and improve resource utilization.

A national study defining 1.0 full-time employment in trauma and acute care surgery.

BACKGROUND: Trauma and acute care surgery (ACS) staffing models vary widely across the United States, resulting in large discrepancies in staffing, compensation, schedule, and clinical/nonclinical expectations. An urgent need exists to define clinical, academic, and schedule expectations for a full-time employment (FTE) of a trauma and ACS surgeon in the United States. METHODS: A survey was distributed to departmental leaders at Levels I, II, III trauma centers across the United States regarding current workload. Variables concerning the responsibilities of surgeons, compensation models, and clinical expectations were collected. This was followed by virtual semistructured interviews of agreeable respondents. A thematic analysis was used to describe current staffing challenges and "ideal" staffing and compensation models of trauma centers. RESULTS: Sixty-eight of 483 division chiefs/medical directors responded (14%), the majority (66%) representing Level I centers. There were differences in clinical responsibilities, elective surgery coverage as well as number of and reimbursement for call. The median description of an FTE was 26 weeks (interquartile range, 13 weeks) with a median of 8 (interquartile range, 8) 12-hour call shifts per month. Level III centers were more likely to perform elective surgery and covered more call shifts, typically from home. In our qualitative interviews, we identified numerous themes, including inconsistent models and staffing of services, surgeon-administration conflict and elective surgery driven by productivity and desire. CONCLUSION: Defining the workload of a full-time trauma and ACS surgeon is nuanced and requires consideration of local volume, acuity and culture. Between the quantitative and qualitative analysis, a reasonable workload for a 1.0 FTE acute care surgeon at a Level I center is 24 to 28 service weeks per year and four to five in-house calls per month. Nighttime and daytime staffing needs can be divergent and may lead to conflict with administration. Future research should consider the individual surgeon's perspective on the definition of an FTE. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis.

OBJECTIVE: To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS: We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION: This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.

2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis.

OBJECTIVE: To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS: We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION: This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.

Racial and Ethnic Disparities in Hospital Admissions from COVID-19: Determining the Impact of Neighborhood Deprivation and Primary Language.

BACKGROUND: Despite past and ongoing efforts to achieve health equity in the USA, racial and ethnic disparities persist and appear to be exacerbated by COVID-19. OBJECTIVE: Evaluate neighborhood-level deprivation and English language proficiency effect on disproportionate outcomes seen in racial and ethnic minorities diagnosed with COVID-19. DESIGN: Retrospective cohort study SETTING: Health records of 12 Midwest hospitals and 60 clinics in Minnesota between March 4, 2020, and August 19, 2020 PATIENTS: Polymerase chain reaction-positive COVID-19 patients EXPOSURES: Area Deprivation Index (ADI) and primary language MAIN MEASURES: The primary outcome was COVID-19 severity, using hospitalization within 45 days of diagnosis as a marker of severity. Logistic and competing-risk regression models assessed the effects of neighborhood-level deprivation (using the ADI) and primary language. Within race, effects of ADI and primary language were measured using logistic regression. RESULTS: A total of 5577 individuals infected with SARS-CoV-2 were included; 866 (n = 15.5%) were hospitalized within 45 days of diagnosis. Hospitalized patients were older (60.9 vs. 40.4 years, p < 0.001) and more likely to be male (n = 425 [49.1%] vs. 2049 [43.5%], p = 0.002). Of those requiring hospitalization, 43.9% (n = 381), 19.9% (n = 172), 18.6% (n = 161), and 11.8% (n = 102) were White, Black, Asian, and Hispanic, respectively. Independent of ADI, minority race/ethnicity was associated with COVID-19 severity: Hispanic patients (OR 3.8, 95% CI 2.72-5.30), Asians (OR 2.39, 95% CI 1.74-3.29), and Blacks (OR 1.50, 95% CI 1.15-1.94). ADI was not associated with hospitalization. Non-English-speaking (OR 1.91, 95% CI 1.51-2.43) significantly increased odds of hospital admission across and within minority groups. CONCLUSIONS: Minority populations have increased odds of severe COVID-19 independent of neighborhood deprivation, a commonly suspected driver of disparate outcomes. Non-English-speaking accounts for differences across and within minority populations. These results support the ongoing need to determine the mechanisms that contribute to disparities during COVID-19 while also highlighting the underappreciated role primary language plays in COVID-19 severity among minority groups.

Characterizing COVID-19 clinical phenotypes and associated comorbidities and complication profiles.

PURPOSE: Heterogeneity has been observed in outcomes of hospitalized patients with coronavirus disease 2019 (COVID-19). Identification of clinical phenotypes may facilitate tailored therapy and improve outcomes. The purpose of this study is to identify specific clinical phenotypes across COVID-19 patients and compare admission characteristics and outcomes. METHODS: This is a retrospective analysis of COVID-19 patients from March 7, 2020 to August 25, 2020 at 14 U.S. hospitals. Ensemble clustering was performed on 33 variables collected within 72 hours of admission. Principal component analysis was performed to visualize variable contributions to clustering. Multinomial regression models were fit to compare patient comorbidities across phenotypes. Multivariable models were fit to estimate associations between phenotype and in-hospital complications and clinical outcomes. RESULTS: The database included 1,022 hospitalized patients with COVID-19. Three clinical phenotypes were identified (I, II, III), with 236 [23.1%] patients in phenotype I, 613 [60%] patients in phenotype II, and 173 [16.9%] patients in phenotype III. Patients with respiratory comorbidities were most commonly phenotype III (p = 0.002), while patients with hematologic, renal, and cardiac (all p<0.001) comorbidities were most commonly phenotype I. Adjusted odds of respiratory, renal, hepatic, metabolic (all p<0.001), and hematological (p = 0.02) complications were highest for phenotype I. Phenotypes I and II were associated with 7.30-fold (HR:7.30, 95% CI:(3.11-17.17), p<0.001) and 2.57-fold (HR:2.57, 95% CI:(1.10-6.00), p = 0.03) increases in hazard of death relative to phenotype III. CONCLUSION: We identified three clinical COVID-19 phenotypes, reflecting patient populations with different comorbidities, complications, and clinical outcomes. Future research is needed to determine the utility of these phenotypes in clinical practice and trial design.

Field-Triage, Hospital-Triage and Triage-Assessment: A Literature Review of the Current Phases of Adult Trauma Triage.

ABSTRACT: Despite major improvements in the United States trauma system over the past two decades, prehospital trauma triage is a significant challenge. Undertriage is associated with increased mortality, and overtriage results in significant resource overuse. The American College of Surgeons Committee on Trauma benchmarks for undertriage and overtriage are not being met. Many barriers to appropriate field triage exist, including lack of a formal definition for major trauma, absence of a simple and widely applicable triage mode, and emergency medical service adherence to triage protocols. Modern trauma triage systems should ideally be based on the need for intervention rather than injury severity. Future studies should focus on identifying the ideal definition for major trauma and creating triage models that can be easily deployed. This narrative review article presents challenges and potential solutions for prehospital trauma triage.