Prospective Outpatient Follow-Up of Early Cognitive Impairment in Patients with Mild Traumatic Brain Injury and Intracranial Hemorrhage.

INTRODUCTION: Mild traumatic brain injury (mTBI) encompasses a spectrum of disability including early cognitive impairment (ECI). The Brain Injury Guidelines (BIG) suggest mTBI patients can be safely discharged from the Emergency Department. Although half of mTBI patients with intracranial hemorrhage (ICH) have evidence of ECI, it is unclear what percentage of these patients' ECI persists after discharge. We hypothesize a significant proportion of trauma patients with mTBI and ECI at presentation have persistent ECI at 30-day follow-up. METHODS: A single-center prospective cohort study including adult trauma patients with ICH or skull fracture plus a Glasgow coma scale (GCS) of 13-15 on arrival was performed. Participants were screened for ECI using the Rancho Los Amigos Scale (RLA), and ECI was defined as a RLA < 8. We compared ECI and non-ECI groups for demographics, injury profile, computed tomography (CT) imaging (e.g., Rotterdam CT score) and outcomes with bivariate analysis. 30-day follow up phone calls were performed to re-evaluate RLA for persistent ECI and concussion symptoms. RESULTS: From 62 patients with ICH or skull fracture and mTBI, 21 (33.9%) had ECI. Patients with ECI had a higher incidence of subarachnoid hemorrhage (85.7% versus 46.3%, p=0.003) and higher Rotterdam CT score (p=0.004) compared to those without ECI. On 30-day follow up, 6 of 21 patients (26.6%) had persistent ECI. In addition, 7 (33.3%) patients had continued concussion symptoms. CONCLUSION: Over one-third of mTBI patients with ICH had ECI. At 30-day post-discharge follow-up over one-fourth of these patients had persistent ECI and 33% had concussion symptoms. This highlights the importance of identifying ECI prior to discharge as a significant portion may have ongoing difficulties reintegrating into work and society.

Comparing Accuracy of Night Radiology Interpretations for Pediatric Trauma: Radiology Residents Versus Attending Teleradiologists.

Background: Overnight radiology coverage for pediatric trauma patients (PTPs) is addressed with a combination of on-call radiology residents (RRs) and/or attending teleradiologists (ATs); however, the accuracy of these two groups has not been investigated for PTPs. We aimed to compare the accuracy of RRs vs AT interpretations of computed tomography (CT) scans for PTPs. Methods: Pediatric trauma patients (<18 years old) at a single level-I adult/level-II pediatric trauma center were studied in a retrospective analysis (3/2019-5/2020). Computed tomography scans interpreted by both RRs and ATs were included. Radiology residents were compared to ATs for time to interpretation (TTI) and accuracy compared to faculty attending radiologist interpretation, using the validated RADPEER scoring system. Additionally, RR and AT accuracies were compared to a previously studied adult cohort during the same time-period. Results: 42 PTPs (270 interpretations) and 1053 adults (8226 interpretations) were included. Radiology residents had similar rates of discrepancy (13.3% vs 13.3%), major discrepancy (4.4% vs 4.4%), missed findings (9.6% vs 12.6%), and overcalls (3.7% vs .7%) vs ATs (all P > .05). Mean TTI was shorter for RRs (55.9 vs 90.4 minutes, P < .001). Radiology residents had a higher discrepancy rate for PTPs (13.3% vs 7.5%, P = .01) than adults. Attending teleradiologists had a similar discrepancy rate for PTPs and adults (13.3% vs 8.9%, P = .07). Discussion: When interpreting PTP CT imaging, RRs had similar discrepancy rates but faster TTI than ATs. Radiology residents had a higher discrepancy rate for PTP CTs than RR interpretation of adult patients, indicating both RRs and ATs need more focused training in the interpretation of PTP studies.

Development of a novel scoring tool to predict the need for early cricothyroidotomy in trauma patients.

Background: The lack of a widely-used tool for predicting early cricothyroidotomy in trauma patients prompted us to develop the Cricothyroidotomy After Trauma (CAT) score. We aimed to predict the need for cricothyroidotomy within one hour of trauma patient arrival. Methods: Derivation and validation datasets were obtained from the Trauma Quality Improvement Program (TQIP) database. Logistic modeling identified predictors, and weighted averages were used to create the CAT score. The score's performance was assessed using AUROC. Results: Among 1,373,823 derivation patients, <1 % (n = 339) underwent cricothyroidotomy within one hour. The CAT score, comprising nine predictors, achieved an AUROC of 0.88. Severe neck injury and gunshot wound were the strongest predictors. Cricothyroidotomy rates increased from 0.4 % to 9.3 % at scores of 5 and 8, respectively. In the validation set, the CAT tool yielded an AUROC of 0.9. Conclusion: The CAT score is a validated tool for predicting the need for early cricothyroidotomy in trauma patients. Further research is necessary to enhance its utility and assess its value in trauma care.

Diagnostic Peritoneal Aspiration or Lavage in Stratified Groups of Hypotensive Blunt Trauma Patients.

BACKGROUND: Some reports suggest Diagnostic peritoneal aspiration (DPA) or lavage (DPL) may better select which hypotensive blunt trauma patients (BTPs) require operation, compared to ultrasonography. However, whether both moderately hypotensive (systolic blood pressure [SBP] < 90 mmHg) and severely hypotensive (SBP < 70 mmHg) patients benefit from DPA/DPL is unclear. We hypothesized DPA/DPL used within the first hour increases risk of death for severely vs moderately hypotensive BTPs. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for BTPs ≥ 18 years old with hypotension upon arrival. We compared moderately and severely hypotensive groups. A multivariable logistic regression analysis was performed controlling for age, comorbidities, emergent operation, blood transfusions, and injury profile. RESULTS: From 134 hypotensive patients undergoing DPA/DPL, 66 (49.3%) had severe hypotension. Patients in both groups underwent an emergent operation (43.9% vs 58.8%, P = .09) in a similar amount of time (median, 42-min vs 54-min, P = .11). Compared to the moderately hypotensive group, severely hypotensive patients had a higher rate and associated risk of death (84.8% vs 50.0%, P < .001) (OR 5.40, CI 2.07-14.11, P < .001). The strongest independent risk factor for death was age ≥ 65 (OR 24.81, CI 4.06-151.62, P < .001). DISCUSSION: Among all BTPs undergoing DPA/DPL within the first hour of arrival, an over 5-fold increased risk of death for patients with severe hypotension was demonstrated. As such, DPA/DPL within this group should be used with caution, particularly for older patients, as they may be better served by immediate surgeries. Future prospective research is needed to confirm these findings and elucidate the ideal DPA/DPL population in the modern era of ultrasonography.

Trauma Patients With Cirrhosis Have a Similar Risk of Unplanned Operation and Decreased Associated Risk of Mortality With Venous Thromboembolism Chemoprophylaxis.

INTRODUCTION: Patients with cirrhosis have an increased risk of complications after trauma, including bleeding, unplanned operations, and death. The benefit of venous thromboembolism (VTE) chemoprophylaxis in trauma patients with cirrhosis (CTPs) is not clear, especially since cirrhotic patients are hypercoagulable. We hypothesized that CTPs receiving VTE chemoprophylaxis (vCP) have a lower risk of death with no increased risk for unplanned operations compared to patients with cirrhosis not receiving vCP. METHODS: The 2017-2019 TQIP database was queried for patients with cirrhosis. Patients on outpatient anticoagulant therapy or with a history of bleeding diathesis, interhospital transfers, severe head injury, deaths < 72 hours, and hospitalization < 2 days were excluded. A multivariable logistic regression analysis was performed. RESULTS: From 10,011 CTPs, 6,350 (63.4%) received vCP. Compared to patients without vCP, the vCP group had decreased mortality (4.5% vs. 5.5%, P = 0.03) but a similar rate of unplanned operations (1% vs. 0.6%, P = 0.07). This persisted on multivariable analysis, with a decreased associated risk of mortality (OR 0.54, CI 0.42-0.69, P < 0.001), and a similar risk of unplanned operation (P = 0.85). CONCLUSION: CTPs received VTE chemoprophylaxis in under two-thirds of cases. On multivariable analysis, vCP was associated with a decreased risk of mortality and a similar risk of unplanned operations. These findings suggest that vCP appears safe. Further investigation is needed to confirm this finding.

The DEPARTS Score: A Novel Tool for Predicting Discharge Disposition in Geriatric Trauma Patients.

BACKGROUND: Geriatric trauma patients (GTPs) represent a high-risk population for needing post-acute care, such as skilled nursing facilities (SNFs) and long-term acute care hospitals (LTACs), due to a combination of traumatic injuries and baseline functional health. As there is currently no well-established tool for predicting these needs, we aimed to create a scoring tool that predicts disposition to SNFs/LTACs in GTPs. METHODS: The adult 2017 Trauma Quality Improvement Program database was divided at random into two equal sized sets (derivation and validation sets) of GTPs >65 years old. First, multiple logistic regression models were created to determine risk factors for discharge to a SNF/LTAC in admitted GTPs. Second, the weighted average and relative impact of each independent predictor was used to derive a DEPARTS (Discharge of Elderly Patients After Recent Trauma to SNF/LTAC) score. We then validated the score using the area under the receiver-operating curve (AROC). RESULTS: Of 66 479 patients in the derivation set, 36 944 (55.6%) were discharged to a SNF/LTAC. Number of comorbidities, fall mechanism, spinal cord injury, long bone fracture, and major surgery were each independent predictors for discharge to SNF/LTAC, and a DEPARTS score was derived with scores ranging from 0 to 19. The AROC for this was .74. In the validation set, 66 477 patients also had a SNF/LTAC discharge rate of 55.7%, and the AROC was .74. DISCUSSION: The DEPARTS score is a good predictor of SNF/LTAC discharge for GTPs. Future prospective studies are warranted to validate its accuracy and clinical utility in preventing delays in discharge.

Laparoscopy in the Evaluation of Blunt Abdominal Injury in Level-I and II Pediatric Trauma Centers.

INTRODUCTION: An American College of Surgeons (ACS) Level-I (L-I) pediatric trauma center demonstrated successful laparoscopy without conversion to laparotomy in ∼65% of trauma cases. Prior reports have demonstrated differences in outcomes based on ACS level of trauma center. We sought to compare laparoscopy use for blunt abdominal trauma at L-I compared to Level-II (L-II) centers. METHODS: The Pediatric Trauma Quality Improvement Program was queried (2014-2016) for patients ≤16 years old who underwent any abdominal surgery. Bivariate analyses comparing patients undergoing abdominal surgery at ACS L-I and L-II centers were performed. RESULTS: 970 patients underwent abdominal surgery with 14% using laparoscopy. Level-I centers had an increased rate of laparoscopy (15.6% vs 9.7%, P = .019); however they had a lower mean Injury Severity Score (16.2 vs 18.5, P = .002) compared to L-II centers. Level-I and L-II centers had similar length of stay ventilator days, and SSIs (all P > .05). CONCLUSION: While use of laparoscopy for pediatric trauma remains low, there was increased use at L-I compared to L-II centers with no difference in LOS or SSIs. Future studies are needed to elucidate which pediatric trauma patients benefit from laparoscopic surgery.

No Difference in Mortality and Outcomes After Addition of a Nearby Pediatric Trauma Center.

OBJECTIVES: Previous studies demonstrate that higher volume pediatric trauma centers (PTCs) offer improved outcomes. This study evaluated pediatric trauma volume and outcomes at an existing level I (L-I) adult and level II (L-II) PTC after the addition of a new children's hospital L-II PTC within a 2-mile radius, hypothesizing no difference in mortality and complications. METHODS: A retrospective review of patients aged 14 years or younger presenting to a single adult L-I and L-II PTC was performed. Patients from 2015-2016 (PRE) were compared with patients from 2018-2019 (POST) for mortality and complications using bivariate analyses. RESULTS: Compared with the PRE cohort, there were less patients in the POST cohort (277 vs 373). Patients in the POST cohort had higher rates of insurance coverage (91.3% vs 78.8%, P < 0.001), self-transportation (7.2% vs 2.7%, P < 0.01), and hospital admission (72.6% and 46.1%, P < 0.001). There was no difference in all complications and mortality (all P > 0.05) between the 2 cohorts. CONCLUSIONS: After opening a second L-II PTC within a 2-mile radius, there was an increase in the rate of admissions and self-transportation to the preexisting L-II PTC. Despite a nearly 26% decrease in pediatric trauma volume, there was no difference in length of stay, hospital complications, or mortality.

Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury.

OBJECTIVES: Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level. METHODS: The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis. RESULTS: The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001). CONCLUSIONS: In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.

Blunt Trauma Mortality: Does Trauma Center Level Matter?

INTRODUCTION: Trauma centers have improved outcomes compared to nontrauma centers when caring for injured patients. A multicenter report found blunt trauma patients treated at American College of Surgeons' Level I trauma centers have improved survival compared to Level II centers. In a subsequent multicenter study, Level II centers had improved survival in all trauma patients. We sought to provide a more granular analysis by stratifying blunt mechanisms-to determine if there was a difference in mortality between Level I and Level II centers. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting to an American College of Surgeons' Level I or II trauma center after blunt trauma. A multivariable logistic regression analysis was performed controlling for comorbidities and Trauma and Injury Severity Score. RESULTS: From 734,473 patients with blunt trauma, 507,715 (69.1%) were treated at a Level I center and 226,758 (30.9%) at a Level II center. The Level I cohort was younger (median age, 53 versus 58, P = 0.01), with a higher median injury severity score (13 versus 10, P < 0.001) and with more patients presenting after a motor vehicle accident (MVA) (27.9% versus 22.4%, P < 0.001) and lower rates of falls (46.6% versus 54.5%, P < 0.001). After adjusting for covariates, there was no difference in mortality between Level I and Level II centers (P > 0.05). When stratifying by mechanisms, Level I centers had a decreased associated mortality for MVA (odds ratio = 0.94, CI: 0.88-0.99, P = 0.04) and bicycle accidents (odds ratio = 0.77, CI: 0.74-0.03, P = 0.01) but no difference in falls or pedestrians struck (P > 0.05). CONCLUSIONS: Overall, blunt trauma patients presenting to a Level I center have no difference in mortality compared to a Level II center. However, when stratified by mechanism, those involved in MVA or bicycle accidents have a decreased associated risk of mortality. Future prospective studies examining variations in practice to account for these differences are warranted.

Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool.

BACKGROUND: Multiple tools predicting massive transfusion (MT) in trauma have been developed but utilize variables that are not immediately available. Additionally, they only differentiate blunt from penetrating trauma and do not account for the large range of blunt mechanisms and their difference in force. We aimed to develop a Blunt trauma Massive Transfusion (B-MaT) score that accounts for high-risk blunt mechanisms and predicts MT needs in blunt trauma patients (BTPs) prior to arrival. MATERIALS AND METHODS: The adult 2017 Trauma Quality Improvement Program database was used to identify BTPs who were divided into 2 sets at random (derivation/validation). First, multiple logistic regression models were created to determine risk factors of MT (≥6 units of PRBCs within 4-hours or ≥10 units within 24-hours). Next, the weighted average and relative impact of each independent predictor was used to derive a B-MaT score. Finally, the area under the receiver-operating curve (AROC) was calculated. RESULTS: Of 172,423 patients in the derivation-set, 1,160 (0.7%) required MT. Heart rate ≥ 120bpm, systolic blood pressure ≤ 90mmHg, and high-risk blunt mechanisms were identified as independent predictors for MT. B-MaT scores were derived ranging from 0 -9, with scores of 6, 7, and 9 yielding a MT rate of 11.7%, 19.4%, and 32.4%, respectively. The AROC was 0.86. The validation-set had an AROC of 0.85. CONCLUSIONS: B-MaT is a novel scoring tool that predicts need for MT in BTPs and can be calculated prior to arrival. B-MaT warrants prospective validation to confirm its accuracy and assess its ability to improve patient outcomes and blood product allocation.

Comparing unbalanced and balanced ratios of blood products in massive transfusion to pediatric trauma patients: effects on mortality and outcomes.

BACKGROUND: The utilization and impact of various ratios of transfusions for pediatric trauma patients (PTPs) receiving a massive transfusion (MT) are unknown. Therefore, we sought to determine the risk for mortality in PTPs receiving an MT of ≥ 6 units of packed red blood cells (PRBC) within 24 h. We compared PRBC: plasma ratio of > 2:1 (Unbalanced Ratios, UR) versus ≤ 2:1 (Balanced Ratios, BR), hypothesizing decreased risk of mortality with BR. METHODS: The Trauma Quality Improvement Program was queried (2014-2016) for PTPs receiving a MT. A multivariable logistic regression model was used to determine risk of mortality. RESULTS: From 239 PTPs receiving an MT, 98 (41%) received an UR, whereas 141 (59%) received a BR. The median ratios, respectively, were 2.7:1 and 1.2:1. Compared to BR patients, UR patients had no differences in injury severity score (ISS), hypotension on admission, and intensive care unit stay (all p > 0.05). The mortality rates for BR and UR were similar (46.1% vs. 52.0%, p = 0.366). Controlling for age, ISS, and severe head injury, UR demonstrated similar risk of mortality compared to BR (p = 0.276). Additionally, ≥ 4:1 ratio versus ≤ 2:1 showed no difference in associated risk of mortality (p = 0.489). CONCLUSION: In contrast to adult studies, this study demonstrated that MT ratios of > 2:1 and even ≥ 4:1 were associated with similar mortality compared to BR for PTPs. These results suggest pediatric MT resuscitation may not require strict BR as has been shown beneficial in adult trauma patients. Future prospective studies are needed to evaluate the optimal ratio for PTP MT resuscitation. LEVEL OF EVIDENCE: III; Retrospective Care Management Study.

Trauma patients with human immunodeficiency virus (HIV): a propensity matched analysis.

BACKGROUND: Given the growing number of people worldwide living with human immunodeficiency virus (HIV), a larger subset of these patients are now susceptible to sustaining a traumatic injury. However, the impact of HIV on outcomes in trauma with modern antiretroviral treatment remains unclear. We hypothesized mortality and rates of infectious and inflammatory complications would be higher in HIV positive (HIV+) trauma patients. METHODS: The Trauma Quality Improvement Program was queried to identify trauma patients ≥ 18 years of age with HIV. Due to the imbalance between HIV+ and HIV negative (HIV-) trauma patients, a 1:2 propensity-matched model was utilized. Matched variables included age, injury severity score, mechanism of injury, systolic blood pressure, pulse rate, Glasgow Coma Scale score, and patient comorbidities. RESULTS: 84 HIV+ patients were matched to 168 HIV- patients. Compared to HIV- patients, HIV+ patients had no significant differences in mortality rate (9.5% vs. 4.8%, p = 0.144) or infectious complications, including pneumonia (6.0% vs. 4.2%, p = 0.530), urinary tract infection (1.2% vs. 1.2%, p = 1.000), or severe sepsis (1.2% vs. 0.0%, p = 0.156). However, higher rates of acute respiratory distress syndrome (ARDS) (9.5% vs. 0.6%, p < 0.001) and acute kidney injury (AKI) (4.8% vs. 0.0%, p = 0.004) were observed. CONCLUSION: HIV+ trauma patients are not at higher risk of mortality or infectious complications, likely due to the advent and prevalence of combination antiretroviral therapy. However, HIV positivity appears to increase the risk of AKI and ARDS in trauma patients. Further research is needed to confirm this finding to elucidate the etiology underlying this association.

Comparison of surgical fixation and non-operative management in patients with traumatic sternum fracture.

PURPOSE: The incidence of sternal fractures in blunt trauma patients lies between 3 and 7%. The role, timing and indications for surgical management are not well delineated and remain controversial for patients undergoing surgical stabilization of sternum fracture (SSSF). We sought to identify the national rate of SSSF in patients with a sternum fracture hypothesizing patients undergoing SSSF will have a decreased rate of mortality and complications. METHODS: The Trauma Quality Improvement Program (2015-2016) was queried for patients with sternum fracture. Propensity scores were calculated to match patients undergoing SSSF to patients managed non-operatively in a 1:2 ratio using demographic data. RESULTS: From 9460 patients with a sternum fracture, 114 (1.2%) underwent SSSF. After propensity-matching, 112 SSSF patients were compared to 224 patients undergoing non-operative management (NOM). There were no differences in matched characteristics (all p > 0.05). Compared to patients undergoing NOM, patients undergoing SSSF had an increased median length of stay (LOS) (16 vs. 7 days, p < 0.001), ICU LOS (9.5 vs. 5.5 days, p = 0.016) and ventilator days (8 vs. 5, p = 0.035). The SSSF group had a similar rate of ARDS (2.7% vs. 2.2%, p = 0.80), pneumonia (1.8% vs. 0.9%, p = 0.48) and unplanned intubation (8.9% vs. 5.8%, p = 0.29) but a lower mortality rate (2.7% vs. 11.2%, p = 0.008). CONCLUSION: Just over 1% of patients with sternum fracture underwent SSSF in a national analysis. Patients undergoing SSSF had an increased LOS and similar rate of all measured pulmonary complications, however a lower mortality rate compared to patients managed non-operatively.

An increasing trend in geriatric trauma patients undergoing surgical stabilization of rib fractures.

PURPOSE: The proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18-64 years old) undergoing SSRF. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed. RESULTS: From 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (p < 0.001) with a geometric-mean-annual increase of 11.5%. GTPs had a lower median injury severity score (18 vs. 22, p < 0.001), but had a higher rate of mortality (4.7% vs. 1.2%, p < 0.001). After controlling for covariates, GTPs had an increased associated risk of mortality (OR 4.80, CI 3.62-6.36, p < 0.001). On a separate multivariate analysis for all trauma patients with isolated chest Abbreviated Injury Scale 3, GTPs were associated with a similar four-fold risk of mortality (OR 4.21, CI 1.98-6.32, p < 0.001). CONCLUSION: Spanning 7 years of data, the proportion of GTPs undergoing SSRF increased by over 7%. Although GTPs undergoing SSRF had lesser injuries, their risk of mortality was four times higher than other adult trauma patients undergoing SSRF, which was similar to their increased background risk of mortality. Ultimately, SSRF in GTPs should be considered on an individualized basis with careful attention to risk-benefit ratio.

Injury and Mortality Profiles in Level II and III Trauma Centers.

BACKGROUND: While the benefit of admission to trauma centers compared to non-trauma centers is well-documented and differences in outcomes between Level-I and Level-II trauma centers are well-studied, data on the differences in outcomes between Level-II trauma centers (L2TCs) and Level-III trauma centers (L3TCs) are scarce. OBJECTIVES: We sought to compare mortality risk between patients admitted to L2TCs and L3TCs, hypothesizing no difference in mortality risk for patients treated at L3TCs compared to L2TCs. METHODS: A retrospective analysis of the 2016 Trauma Quality Improvement Program (TQIP) database was performed. Patients aged 18+ years were divided into 2 groups, those treated at American College of Surgeons (ACS) verified L2TCs and L3TCs. RESULTS: From 74,486 patients included in this study, 74,187 (99.6%) were treated at L2TCs and 299 (.4%) at L3TCs. Both groups had similar median injury severity scores (ISSs) (10 vs 10, P < .001); however, L2TCs had a higher mean ISS (14.6 vs 11.9). There was a higher mortality rate for L2TC patients (6.0% vs 1.7%, P = .002) but no difference in associated risk of mortality between the 2 groups (OR .46, CI .14-1.50, P = .199) after adjusting predictors of mortality. L2TC patients had a longer median length of stay (5.0 vs 3.5 days, P < .001). There was no difference in other outcomes including myocardial infarction (MI) and cerebrovascular accident (CVA) (P > .05). DISCUSSION: Patients treated at L2TCs had a longer LOS compared to L3TCs. However, after controlling for covariates, there was no difference in associated mortality risk between L2TC and L3TC patients.

A Dual Pandemic: The Influence of Coronavirus Disease 2019 on Trends and Types of Firearm Violence in California, Ohio, and the United States.

BACKGROUND: This study sought to determine the impact of coronavirus disease 2019 stay-at-home (SAH) and reopening orders on trends and types of firearm violence in California, Ohio, and the United States, hypothesizing increased firearm violence after SAH. MATERIALS AND METHODS: Retrospective data (January 1, 2018, to July 31, 2020) on firearm incidents/injuries/deaths and types of firearm violence were obtained from the Gun Violence Archive. The periods for SAH and reopening for the US were based on dates for California. Ohio dates were based on Ohio's timeline. Mann-Whitney U analyses compared trends and types of daily firearm violence per 100,000 legal firearm owners across 2018-2020 periods. RESULTS: In California, SAH and reopening orders had no effect on firearm violence in 2020 compared with 2018 and 2019 periods, respectively. In Ohio, daily median firearm deaths increased during 2020 SAH compared with 2018 and 2019 and firearm incidents and injuries increased during 2020 reopening compared with 2018, 2019 and 2020 SAH. In the United States, during 2020, SAH firearm deaths increased compared with historical controls and firearm incidents, deaths and injuries increased during 2020 reopening compared with 2018, 2019 and 2020 SAH (all P < 0.05). Nationally, when compared with 2018 and 2019, 2020 SAH had increased accidental shootings deaths with a decrease in defensive use, home invasion, and drug-involved incidents. CONCLUSIONS: During 2020 SAH, the rates of firearm violence increased in Ohio and the United States but remained unchanged in California. Nationally, firearm incidents, deaths and injuries also increased during 2020 reopening versus historical and 2020 SAH data. This suggests a secondary "pandemic" as well as a "reopening phenomenon," with increased firearm violence not resulting from self-defense.

Isolated Thoracic Injury Patients With Rib Fractures Undergoing Rib Fixation Have Improved Mortality.

BACKGROUND: Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF. MATERIALS AND METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed. RESULTS: From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF. CONCLUSIONS: The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay.

A national analysis of pediatric firearm violence and the effects of race and insurance status on risk of mortality.

OBJECTIVES: To perform a national analysis of pediatric firearm violence (PFV), hypothesizing that black and uninsured patients would have higher risk of mortality. METHODS: The Trauma Quality Improvement Program (2014-2016) was queried for PFV patients ≤16 years-old. Multivariable logistic regression models on all patients and a subset excluding severe brain injuries were performed. RESULTS: The PFV mortality rate was 11.2%. 66.5% of PFV patients were black (p < 0.001). Deceased patients were more likely to be uninsured (14.5% vs. 5.3%, p < 0.001). Black race was an associated risk factor for mortality in patients without severe brain injury (OR 5.26, CI 1.00-27.47, p = 0.049) but not for the overall population (OR 1.32, CI 0.68-2.56, p = 0.39). CONCLUSION: Nearly two-thirds of PFV patients were black. Contrary to previous studies, black and uninsured pediatric patients did not have an increased risk of mortality overall. However, in a subset of patients without severe brain injury, black race was associated with increased mortality risk. SUMMARY: Between 2014 and 2016 the mortality rate for pediatric firearm violence (PFV) in children 16 years and younger was 11.2%. Although two-thirds of PFV patients were black, black race and lack of insurance were not risk factors of mortality for the overall population. Once patients with severe brain injury were excluded, black race and became associated with an increased risk of mortality.

Minimally Invasive Hernia Repair in Robot-assisted Radical Prostatectomy.

Inguinal hernia is a recognized complication of radical prostatectomy. Previous hernia repair, wound infection, midline incision, low BMI, and preexisting or subclinical hernia contribute to the risk of inguinal hernia following radical prostatectomy. Concomitant hernia repair at the time of pelvic surgery has risks and benefits. Repair during surgery prevents future hernia-related complications and saves the need for an additional procedure. However, hernia repair at the time of radical prostatectomy includes the risk of mesh infection, post-operative pain, adhesions, lack of experience, and overall minimal risk with watchful waiting. The robotic transperitoneal approach is the most commonly used technique for concomitant inguinal hernia repair with a modest addition to operative time and minimal postoperative complications. Recurrence rates following concomitant hernia repair during pelvic surgery are low.