Characterization of patients requiring inpatient hospital ethics consults- A single center study.

INTRODUCTION: Ethics consultations are often needed at difficult junctures of medical care. However, data on the nature of how patient characteristics, including race/ethnicity, language, and diagnosis, affect ethics consult outcomes are lacking. METHODS: We performed a retrospective cohort study of all patients who were seen by the Ethics Consult Service between 2017 and 2021 at a large tertiary academic center with the aim of determining whether patient demographic and clinical factors were associated with the timing of ethics consult requests and recommendations of the ethics team. RESULTS: We found that patients admitted for COVID-19 had significantly longer median times to consult from admission compared with other primary diagnoses (19 vs 8 days respectively, p = 0.015). Spanish-speaking patients had longer median times to consult from admission compared to English speaking patients (20 vs 7 days respectively, p = 0.008), indicating that language barriers may play a role in the timing of ethics consultation. CONCLUSIONS: This study demonstrates the need to consider clinical and demographic features when planning and prioritizing ethics consultations at large institutions to enhance consult efficiency, resource utilization, and patient experience and autonomy.

Variability in Standardized Mortality Rates Among Pediatric Traumatic Brain Injury Patients: A Comparative Analysis of Trauma Centers.

INTRODUCTION: Traumatic brain injury (TBI) causes significant morbidity and mortality in pediatric patients and care is highly variable. Standardized mortality ratio (SMR) summarizes the mortality rate of a specific center relative to the expected rates across all centers, adjusted for case-mix. This study aimed to evaluate variations in SMRs among pediatric trauma centers for TBI. METHODS: Patients aged 1-18 diagnosed with TBI within the National Trauma Data Bank (NTDB) from 2017 to 2019 were included. Center-specific SMRs and 95% confidence intervals identified centers with mortality rates significantly better or worse than the median SMR for all centers. RESULTS: 316 centers with 10,598 patients were included. SMRs were risk-adjusted for patient risk factors. Unadjusted mortality ranged from 16.5 to 29.5%. Three centers (1.5%) had significantly better SMR (SMR <1) and three centers (1.5%) had significantly worse SMR (SMR >1). Significantly better centers had a lower proportion of neurosurgical intervention (2.4% vs. 11.8%, p < 0.001), a higher proportion of supplemental oxygen administration (93.7% vs. 83.5%, p = 0.004) and venous thromboembolism prophylaxis (53.2% vs. 40.6%, p < 0.001) compared to significantly worse centers. CONCLUSIONS: This study identified centers that have significantly higher and lower mortality rates for pediatric TBI patients relative to the overall median rate. These data provide a benchmark for pediatric TBI outcomes and institutional quality improvement. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective Comparative Study.

Washington State Assault Weapon Firearm Violence Before and After Firearm Legislation Reform.

BACKGROUND: In January of 2019, Washington State (WA) passed Initiative 1639 making it illegal for persons <21 years-old to buy assault weapons (AWs). This study aimed to evaluate the effects of WA-1639 on firearm-related incidents involving AWs by those <21 years-old in WA, hypothesizing a decrease in incidents after WA-1639. METHODS: Retrospective (2016-2021) data on firearm violence (FV) events were gathered from the Gun Violence Archive. The rate of FV was weighted per 100,000 people. Total monthly incidents, injuries, and deaths were compared pre-law (January 2016-December 2018) vs post-law (January 2019-December 2021) implementation. Mann-Whitney U tests and Poisson's regression were used for analysis. RESULTS: From 4091 FV incidents (2210 (54.02%) pre-law vs 1881 (45.98%) post-law), 50 involved AWs pre- (2.3%) and 15 (.8%) post-law. Of these, 11 were committed by subjects <21 years-old pre-law and only one occurred post-law. Total incidents of FV (z = -3.80, P < .001), AW incidents (z = -4.28, P < .001), and AW incidents involving someone <21 years-old (z = -3.01, P < .01) decreased post-law. Additionally, regression analysis demonstrated the incident rate ratio (IRR) of all FV (1.23, 95% CI [1.10-1.38], P < .001), all AW FV incidents (3.42, 95% CI [1.70-6.89], P = .001), and AW incidents by subjects <21 years-old (11.53, 95% CI [1.52-87.26], P = .02) were greater pre-law vs post-law. DISCUSSION: Following implementation of WA-1639, there was a significant decrease in FV incidents and those involving AWs by individuals <21 years-old. This suggests targeted firearm legislation may help curtail FV. Further studies evaluating FV after legislation implementation in other states is needed to confirm these findings.

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.

Neurosurgery compared to orthopedic spine consultation: A single level I trauma center experience.

Introduction: Both Orthopedic Surgery (OS) and Neurosurgery (NS) perform spine surgery in the setting of trauma. However, it is unknown whether outcomes differ between these specialties. This study compares management and outcomes for vertebral fractures between NS and OS, hypothesizing similar operation rate, length of stay (LOS), and readmission. Research question: Do outcomes differ between NS and OS in the management of vertebral fractures following trauma? Methods: A retrospective single-center study was conducted on adult patients with cervical, thoracic, lumbar, and sacral fractures treated at a single trauma center, where no standardized pathway exists across NS and OS. Patients were compared for injury profile, diagnostic imaging, and operative techniques as well as LOS, mortality, and complications. Results: A total of 630 vertebral fracture patients (OS:350 (55.6%); NS:280 (44.4%)) were included. NS utilized magnetic resonance imaging (MRI) more commonly (36.4% vs. 22.6%, p < 0.001). NS patients more often underwent operation (13.2% vs. 7.4%, p = 0.016) despite similar fracture number and severity (p > 0.05). Post-operative complications, LOS, and readmission rates were similar between cohorts (p > 0.05). Discussion and conclusion: Despite similar injury profiles, NS had higher rates of MRI usage and operative interventions in the context of traumatic spine fractures. Despite differences in management, major clinical outcomes were similar between NS and OS. However, we do call for further standardization of evaluation and treatment of patients based on established algorithms from such as the AOSpine Thoracolumbar Spine Injury Classification System (ATLICS).

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.

iPad-Based Neurocognitive Testing (ImPACT-QT) in Acute Adult Mild Traumatic Brain Injury/Concussion: Study on Practicality and Bedside Cognitive Scores in a Level-1 Trauma Center.

BACKGROUND: There lacks rapid standardized bedside testing to screen cognitive deficits following mild traumatic brain injury (mTBI). Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test (ImPACT-QT) is an abbreviated-iPad form of computerized cognitive testing. The aim of this study is to test ImPACT-QT utility in inpatient settings. We hypothesize ImPACT-QT is feasible in the acute trauma setting. METHOD: Trauma patients ages 12-70 were administered ImPACT-QT (09/2022-09/2023). Encephalopathic/medically unstable patients were excluded. Mild traumatic brain injury was defined as documented-head trauma with loss-of-consciousness <30 minutes and arrival Glasgow Coma Scale 13-15. Patients answered Likert-scale surveys. Bivariate analyses compared demographics, attention, motor speed, and memory scores between mTBI and non-TBI controls. Multivariable logistic regression assessed memory score as a predictor of mTBI diagnosis. RESULTS: Of 233 patients evaluated (36 years [IQR 23-50], 71% [166/233] female), 179 (76%) were mTBI patients. For all patients, mean test-time was 9.3 ± 2 minutes with 93% (73/76) finding the test "easy to understand." Mild traumatic brain injury patients than non-TBI control had lower memory scores (25 [IQR 7-100] vs 43 [26-100], P = .001) while attention (5 [1-23] vs 11 [1-32]) and motor score (14 [3-28] vs 13 [4-32]) showed no significant differences. Multivariable-regression (adjustment: age, sex, race, education level, ISS, and time to test) demonstrated memory score predicted mTBI positive status (OR .96, CI .94-.98, P = .004). DISCUSSION: Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test is feasible in trauma patients. Preliminary findings suggest acute mTBIs have lower memory but not attention/motor scores vs non-TBI trauma controls.

Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study.

INTRODUCTION: To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use. METHODS: Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were. CONCLUSIONS: Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.

The Relationship Between the COVID-19 Pandemic and Pediatric Trauma.

INTRODUCTION: The COVID-19 pandemic created difficulties in access to care. There was also increased penetrating trauma in adults, which has been attributed to factors including increased firearm sales and social isolation. However, less is known about the relationship between the pandemic and pediatric trauma patients (PTPs). This study aimed to investigate the national incidence of penetrating trauma in PTPs, hypothesizing a higher rate with onset of the pandemic. We additionally hypothesized increased risk of complications and death in penetrating PTPs after the pandemic versus prepandemic. METHODS: We included all PTPs (aged ≤17-years-old) from the 2017-2020 Trauma Quality Improvement Program database, dividing the dataset into two eras: prepandemic (2017-2019) and pandemic (2020). We performed subset analyses of the pandemic and prepandemic penetrating PTPs. Bivariate analyses and a multivariable logistic regression analysis were performed. RESULTS: Of the 474,524 PTPs, 123,804 (26.1%) were from the pandemic year. The pandemic era had increased stab wounds (3.3% versus 2.8%, P > 0.001) and gunshot wounds (5.5% versus 4.0%, P < 0.001) compared to the prepandemic era. Among penetrating PTPs, the rates and associated risk of in-hospital complications (2.6% versus 2.8%, P = 0.23) (odds ratio 0.90, confidence interval 0.79-1.02, P = 0.11) and mortality (4.9% versus 5.0%, P = 0.58) (odds ratio 0.90, confidence interval 0.78-1.03, P = 0.12) were similar between time periods. CONCLUSIONS: This national analysis confirms increased penetrating trauma, particularly gunshot wounds in pediatric patients following onset of the COVID-19 pandemic. Despite this increase, there was no elevated risk of death or complications, suggesting that trauma systems adapted to the "dual pandemic" of COVID-19 and firearm violence in the pediatric population.

Immediate Operative Trauma Assessment Score: A Simple and Reliable Predictor of Mortality in Trauma Patients Undergoing Urgent/Emergent Surgery.

Objective: Many current trauma mortality prediction tools are either too intricate or rely on data not readily available during a trauma patient's initial evaluation. Moreover, none are tailored to those necessitating urgent or emergent surgery. Our objective was to design a practical, user-friendly scoring tool using immediately available variables, and then compare its efficacy to the widely-known Revised Trauma Score (RTS). Methods: The adult 2017-2021 Trauma Quality Improvement Program (TQIP) database was queried to identify patients ≥18 years old undergoing any urgent/emergent operation (direct from Emergency Department to operating room). Patients were divided into derivation and validation groups. A three-step methodology was used. First, multiple logistic regression models were created to determine risk of death using only variables available upon arrival. Second, the weighted average and relative impact of each independent predictor was used to derive an easily calculated Immediate Operative Trauma Assessment Score (IOTAS). We then validated IOTAS using AUROC and compared it to RTS. Results: From 249 208 patients in the derivation-set, 14 635 (5.9%) died. Age ≥65, Glasgow Coma Scale score <9, hypotension (SBP <90 mmHg), and tachycardia (>120/min) on arrival were identified as independent predictors for mortality. Using these, the IOTAS was structured, offering scores between 0-8. The AUROC for this was .88. A clear escalation in mortality was observed across scores: from 4.4% at score 1 to 60.5% at score 8. For the validation set (250 182 patients; mortality rate 5.8%), the AUROC remained consistent at .87, surpassing RTS's AUROC of .83. Conclusion: IOTAS is a novel, accurate, and now validated tool that is intuitive and efficient in predicting mortality for trauma patients requiring urgent or emergent surgeries. It outperforms RTS, and thereby may help guide clinicians when determining the best course of action in patient management as well as counseling patients and their families.

Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study.

Objectives: There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods: A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results: A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion: NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence: IV.

High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study.

BACKGROUND: High-grade liver injuries with extravasation (HGLI â€‹+ â€‹Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â€‹+ â€‹Extrav. Therefore, we evaluated the management of HGLI â€‹+ â€‹Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â€‹+ â€‹Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â€‹= â€‹0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â€‹> â€‹0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â€‹+ â€‹Extrav patients.

To close or not to close? Wound management in emergent colorectal surgery, an EAST Multicenter prospective cohort study.

BACKGROUND: To determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS) and mortality in emergent colorectal surgery. METHODS: A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, ICU admission, vasopressor use, procedure details and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS: In total, 557 patients were included (SC n = 262, SLC n = 124, SO n = 171). Statistically significant differences in BMI, race/ethnicity, ASA scores, EBL, ICU admission, vasopressor therapy, procedure details, and wound class were observed across groups (Table 1). Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group (Table 2). After risk adjustment, SO was associated with increased risk of mortality (OR = 3.003, p = 0.028 in comparison to the SC group. SLC was associated with increased risk of superficial SSI (OR = 3.439, p = 0.014), after risk adjustment. CONCLUSION: When compared to the SC group, the SO group was associated with mortality, but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. STUDY TYPE: Level III Therapeutic/Care Management.

Outcomes of severely injured pregnant trauma patients: a multicenter analysis.

Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26 weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population.

Domestic firearm violence against women (2018-2021).

Background: Over 50 % of US female homicides occur during domestic violence, with half involving firearms. Public health measures to control COVID-19 may have isolated individuals with abusive partners at a time when firearm sales and new firearm ownership surged. This study sought to evaluate trends in domestic firearm violence (DFV) over time, hypothesizing that rates of DFV increased in the wake of COVID-19. Materials and methods: A retrospective query of the Gun Violence Archive (2018-2021) was conducted for incidents of DFV. The primary outcome was the number of DFV-related shootings. Statistical testing, including one-way and two-way ANOVAs, was performed to compare monthly rates of DFV over time and to compare DFV per 100,000 women in states with strong versus weak gun laws. Results: Average monthly DFV incidents rose nationwide during this study's time period, though injuries and fatalities did not. States with weaker gun laws had increased incidents, deaths, and injuries from 2018 to 2021 (all p<0.05). In a two-way ANOVA, stronger gun laws were associated with fewer incidents of DFV when compared with weaker gun law states. We also found that the use of a long gun in DFV more often resulted in a victim's death when compared to a handgun (p<0.01). Conclusion: DFV incidents increased over time. States with weaker gun laws bore the brunt of the violence, demonstrating that DFV may be curtailed through legislative efforts. Methods of injury prevention aimed at preventing and reducing domestic violence and improving firearm safety may curtail DFV.

Blunt Adrenal Injury is Not Associated With Worse Outcomes in Adult Trauma Patients.

INTRODUCTION: Blunt adrenal injury is rare. Given production of hormones including catecholamines, adrenal injury may lead to worse outcomes. However, there is a paucity of literature on this topic. As such, we compared blunt trauma patients (BTPs) with and without adrenal injuries, hypothesizing similar mortality and complications between cohorts. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adult (≥18-year-old) BTPs. Patients with penetrating trauma, traumatic brain injury, severe thoracic injury, or who were transferred from another hospital were excluded. Patients with adrenal injury were compared to those without using a 1:2 propensity score model. Matched variables included patient age, comorbidities, vitals on admission and concomitant injuries (i.e., liver, spleen, kidney, pancreas, and hollow viscus). Univariable logistic regression was then performed for associated risk of mortality. RESULTS: 2287 (0.2%) BTPs had an adrenal injury, with 1470 patients with adrenal injury matched to 2940 without adrenal injury. The rate of all complications including sepsis (0.1% versus 0.0%) was similar between cohorts (all P > 0.05). Patients with adrenal injury had a lower rate of mortality (0.1% versus 0.6%, P = 0.035) but increased length of stay (4 [3-6] versus 3 [2-5] days, P = 0.002). However, there was no difference in associated risk of mortality for patients with and without adrenal injury (odds ratio = 0.234; confidence interval = 0.54-1.015; P = 0.052). CONCLUSIONS: Blunt adrenal injury occurred in <1% of patients. After propensity matching, there was a similar associated rate of complications but longer hospital length of stay for patients with adrenal injury. Adrenal injury was not associated with an increased risk of mortality.

Similar rate of venous thromboembolism (VTE) and failure of non-operative management for early versus delayed VTE chemoprophylaxis in adolescent blunt solid organ injuries: a propensity-matched analysis.

BACKGROUND: Early initiation of venous thromboembolism (VTE) chemoprophylaxis in adults with blunt solid organ injury (BSOI) has been demonstrated to be safe but this is controversial in adolescents. We hypothesized that adolescent patients with BSOI undergoing non-operative management (NOM) and receiving early VTE chemoprophylaxis (eVTEP) (≤ 48 h) have a decreased rate of VTE and similar rate of failure of NOM, compared to similarly matched adolescents receiving delayed VTE chemoprophylaxis (dVTEP) (> 48 h). METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adolescents (12-17 years of age) with BSOI (liver, kidney, and/or spleen) undergoing NOM. We compared eVTEP versus dVTEP using a 1:1 propensity score model, matching for age, comorbidities, BSOI grade, injury severity score, hypotension on arrival, and need for transfusions. We performed subset analyses in patients with isolated spleen, kidney, and liver injury. RESULTS: From 1022 cases, 417 (40.8%) adolescents received eVTEP. After matching, there was no difference in matched variables (all p > 0.05). Both groups had a similar rate of VTE (dVTEP 0.6% vs. eVTEP 1.7%, p = 0.16), mortality (dVTEP 0.3% vs. eVTEP 0%, p = 0.32), and failure of NOM (eVTEP 6.7% vs. dVTEP 7.3%, p = 0.77). These findings remained true in all subset analyses of isolated solid organ injury (all p > 0.05). CONCLUSIONS: The rate of VTE with adolescent BSOI is exceedingly rare. Early VTE chemoprophylaxis in adolescent BSOI does not increase the rate of failing NOM. However, unlike adult trauma patients, adolescent patients with BSOI receiving eVTEP had a similar rate of VTE and death, compared to adolescents receiving dVTEP.

Trends in Legal Firearm Transactions: A Possible Protective Role of Gun Law Strength.

INTRODUCTION: The United States (US) holds the highest personal firearm ownership among industrialized nations, with implications for firearm-related deaths tied to increased per capita gun ownership and varying gun laws. This study examines the influence of gun law strength on legal firearm transactions, positing a correlation between stronger laws and reduced transactions. The analysis, focused on the stress-laden COVID-19 pandemic, evaluates handgun, long gun, and multiple gun transactions in 2020 and 2021 compared to 2018-2019. METHODS: The Giffords Gun Law scorecard categorized states into the top 25 "strong" and bottom 25 "weak" gun law groups. Multivariate linear regressions assessed the association between strong gun law states and monthly National Instant Criminal Background Check System (NICS) data from 2018 to 2021. The study queried NICS for handgun, long gun, and multiple gun transactions, comparing median monthly transactions in 2018 and 2019 to 2020 and 2018-2020 to 2021. RESULTS: When evaluating gun law strength through multivariate linear regression models, stronger gun law states had fewer monthly NICS transactions for handguns, long guns, and multiple guns in 2020 and 2021 versus all comparison years (all P < .05). However, from 2018-2019 to 2020 and 2018-2020 to 2021, median monthly NICS transactions per 100,000 people for all gun types increased (all P < .05). CONCLUSION: Stricter gun laws correlated with decreased firearm transactions in stronger law states, yet handgun, long gun, and multiple gun transactions increased during the pandemic years of 2020 and 2021. Therefore, strengthening firearm legislation may be protective against the proliferation of firearms, which warrants further research.

Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study.

BACKGROUND: Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications. METHODS: Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables. RESULTS: Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31 h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment. DISCUSSION: Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3 days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.