Crossing the line: access to trauma care across state borders.

Objective: This study investigates the challenge posed by state borders by identifying the population, injury, and geographic scope of areas of the country where the closest trauma center is out-of-state, and by collating state emergency medical services (EMS) policies relevant to cross-border trauma transport. Methods: We identified designated levels I, II, and III trauma centers using data from American Trauma Society. ArcGIS was used to map the distance between US census block groups and trauma centers to identify the geographic areas for which cross-border transport may be most expedient. National Highway Traffic Safety Administration data were queried to quantify the proportion of fatal crashes occurring in the areas of interest. State EMS protocols were categorized by stance on cross-border transport. Results: Of 237 596 included US census block groups, 18 499 (7.8%) were closest to an out-of-state designated level I or II trauma center. These census block groups accounted for 6.9% of the US population and 9.5% of all motor vehicle fatalities. With the inclusion of level III trauma centers, the number of US census block groups closest to an out-of-state designated level I, II, or III trauma center decreased to 13 690 (5.8%). These census block groups accounted for 5.1% of the US population and 7.1% of all motor vehicle fatalities. Of the 48 contiguous states, 30 encourage cross-border transport, 2 discourage it, 12 are neutral, and 4 leave it to local discretion. Conclusion: Cross-border transport can expedite access to care in at least 5% of US census block groups. While few states discourage this practice, more robust policy guidance could reduce delays and enhance care. Level of Evidence: III, Epidemiological.

The influence of different horseshoes and ground substrates on mid-stance hoof orientation at the walk.

BACKGROUND: Horseshoes with modified contact surfaces combined with deformable ground substrates are used to change hoof orientation during mid-stance, for example, for therapeutic reasons. OBJECTIVES: To measure the effect of horseshoes and ground substrates on sagittal and transverse plane hoof orientation at mid-stance using a dorsal hoof wall mounted triaxial accelerometer. STUDY DESIGN: In vivo experiment, randomised crossover design. METHODS: Differences in sagittal and transverse plane angles between standing and mid-stance of the left front hoof of six horses walking with regular horseshoes, egg bar, toe-wide, medial-wide, lateral-wide and three-degree egg bar shoes on turf, sand and hard ground substrates were assessed with linear mixed models with horseshoe and substrate type as fixed factors (p < 0.05) for each animal. RESULTS: Hoof angles were significantly affected by horseshoe (p < 0.001), surface (p < 0.001) and the combination (p < 0.001). The sagittal plane angle increased in deformable ground substrates at walk-in mid-stance on turf [mean (±standard deviation): 2.6° (±3.8°)] and on sand [2.6° (±4.1°)] across all shoes. The greatest increase was observed with egg bar shoes [turf: 4.37° (±3.82°); sand 4.69° (±3.83°)]. There was a tendency for the hoof to sink laterally into deformable ground substrates among all shoes [turf: 1.11° (±1.49°); sand: 0.93° (±1.93°)]. Medial-wide shoes increased the lateral sinking [turf: 2.00° (±1.63°); sand: 1.79° (±1.58°)]. Lateral-wide shoes reduced the lateral sinking on turf [0.62° (±1.26°)] and induced a marginal medial sinking on sand [-0.007° (±2.03°)]. MAIN LIMITATIONS: The substrate properties were not quantitatively assessed, and observations were limited to front hooves at the walk. A larger sample size would be preferable. CONCLUSIONS: Mid-stance hoof orientation changes with specific combinations of shoes and ground substrates in the walking horse.

CONTEXTO: É especulado que ferraduras com solados diferentes combinadas com superfícies deformáveis podem mudar a orientação do casco durante a fase de apoio, por exemplo, por razões terapêuticas. OBJETIVOS: Mensurar o efeito de diferentes ferraduras e superfícies na orientação do casco nos planos sagital e transversal durante a fase de apoio usando um acelerômetro triaxial acoplado à parte dorsal do casco. DELINEAMENTO DO ESTUDO: Experimento in vivo, delineamento randomizado e cruzado. MÉTODOS: As diferenças entre os ângulos dos planos sagital e transverso nas diferentes fases de apoio do casco do membro anterior esquerdo de seis cavalos ao passo utilizando ferradura normal, oval, oval talonada, de pinça larga e com extensão medial ou lateral na grama, areia ou superfície dura foram avaliadas utilizando modelos mistos lineares com ferradura e tipo de superfície como fatores fixos (P < 0.05) para cada animal. RESULTADOS: Os ângulos do casco foram significativamente afetados pelo tipo de ferradura (P < 0.001), superfície (P < 0.001) e pela combinação de ambos (P < 0.001). O ângulo do plano sagital aumentou em superfícies deformáveis no passo na fase de apoio na grama (média (+/-SD): 2.6 (+/−3.8) graus) e na areia (2.6 (+/−4.1 graus) para todos os tipos de ferradura. O maior aumento foi observado com a ferradura oval (grama: 4.37 (+/− 3.82) graus; areia 4.69 (+/−3.83) graus). Houve uma tendência de o casco rebaixar mais lateralmente em superfícies deformáveis com todas as ferraduras (grama: 1.11 (+/−1.49) graus; areia: 0.93 (+/−1.93) graus). Ferraduras com extensão medial aumentaram o rebaixamento lateral (grama: 2.00 (+/−1.63) graus; areia: 1.79 (+/−1.58) graus). Ferraduras com extensão lateral reduziram o rebaixamento lateral na grama (0.62 (+/−1.26) graus) e induziram o rebaixamento medial na areia (−0.007 (+/−2.03) graus). PRINCIPAIS LIMITAÇÕES: As propriedades das superfícies não foram avaliadas quantitativamente, e as observações foram limitadas aos cascos dos membros anteriores e ao passo. Um número maior de animais no estudo seria desejável. CONCLUSÕES: A orientação do casco na fase de apoio muda de acordo com combinações específicas de ferradura e superfícies no cavalo ao passo.

Effects of prior injury on long term patient reported outcomes after trauma.

BACKGROUND: Trauma is an episodic, chronic disease with substantial, long-term physical, psychological, emotional, and social impacts. However, the effect of recurrent trauma on these long-term outcomes remains unknown. We hypothesized that trauma patients with a history of prior traumatic injury (PTI) would have poorer outcomes 6 months (6mo) after injury compared with patients without PTI. METHODS: Adult trauma patients admitted at an urban, academic, Level I trauma center were screened for inclusion (October 2020 to November 2021). Enrolled patients were administered the PROMIS-29 instrument, the primary care post-traumatic stress disorder screen, and standardized questions about prior trauma hospitalization, substance use, employment, and living situation at baseline and 6mo after injury. Assessment data was merged with clinical registry data, and outcomes were compared with respect to PTI. RESULTS: Of 3,794 eligible patients, 456 completed baseline assessments and 92 completed 6mo surveys. Between those with or without PTI, there were no differences at 6mo after injury in the proportion of patients reporting poor function in social participation, anxiety, depression, fatigue, pain interference, or sleep disturbance. Prior traumatic injury patients reported poor physical function less often than patients without PTI (10 [27.0%] vs. 33 [60.0%], p = 0.002). After controlling for age, gender, race, injury mechanism, and Injury Severity Score, PTI correlated with a fourfold decrease in poor physical function risk (adjusted odds ratio, 0.243; 95% confidence interval, 0.081-0.733; p = 0.012) in the multivariable logistic regression model. CONCLUSION: Compared with patients suffering their first injury, trauma patients with PTI have better self-reported physical function after a subsequent injury and otherwise equivalent outcomes across a range of HRQoL domains at 6mo. There remains substantial room for improvement to mitigate the long-term challenges faced by trauma patients and to facilitate their societal reintegration, regardless of the number of times they are injured. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions.

INTRODUCTION: Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially. METHODS: We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients. RESULTS: A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes. CONCLUSIONS: The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.

National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions.

INTRODUCTION: Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken. METHODS: Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes. RESULTS: One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation. CONCLUSIONS: Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.

The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions: A Retrospective Observational Study Using an Instrumental Variable Analysis.

OBJECTIVE: To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions. BACKGROUND: EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity. METHODS: Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions. RESULTS: Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P < 0.001; nonmultimorbid: -11.9%, P < 0.001) and 30-day readmissions (multimorbid: -8.2%, P = 0.002; nonmultimorbid: -9.7%, P < 0.001) among hepatobiliary patients. CONCLUSIONS: The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients.

Higher center volume is significantly associated with lower mortality in trauma patients with shock.

INTRODUCTION: Injured patients presenting in shock are at high risk of mortality despite numerous efforts to improve resuscitation. Identifying differences in outcomes among centers for this population could yield insights to improve performance. We hypothesized that trauma centers treating higher volumes of patients in shock would have lower risk-adjusted mortality. METHODS: We queried the Pennsylvania Trauma Outcomes Study from 2016 to 2018 for injured patients ≥16 years of age at Level I&II trauma centers who had an initial systolic blood pressure (SBP) of <90 mmHg. We excluded patients with critical head injury (abbreviated injury score [AIS] head ≥5) and patients coming from centers with a shock patient volume of ≤10 for the study period. The primary exposure was tertile of center-level shock patient volume (low, medium, or high volume). We compared risk-adjusted mortality by tertile of volume using multivariable Cox proportional hazards model incorporating age, injury severity, mechanism, and physiology. RESULTS: Of 1,805 included patients at 29 centers, 915 (50.7%) died. The median annual shock trauma patient volume was 9 patients for low volume centers, medium 19.5, and high 37. Median ISS was higher at high volume compared to low volume centers (22 vs 18, p <0.001). Raw mortality was 54.9% at high volume centers, 46.7% for medium, and 42.9% for low. Time elapsed from arrival to emergency department (ED) to the operating room (OR) was lower at high volume than low volume centers (median 47 vs 78 min) p = 0.003. In adjusted analysis, hazard ratio for high volume centers (referenced to low volume) was 0.76 (95% CI 0.59-0.97, p = 0.030). CONCLUSION: After adjusting for patient physiology and injury characteristics, center-level volume is significantly associated with mortality. Future studies should seek to identify key practices associated with improved outcomes in high-volume centers. Furthermore, shock patient volume should be considered when new trauma centers are opened.

CH4 and N2 O emissions from smallholder agricultural systems on tropical peatlands in Southeast Asia.

There are limited data for greenhouse gas (GHG) emissions from smallholder agricultural systems in tropical peatlands, with data for non-CO2 emissions from human-influenced tropical peatlands particularly scarce. The aim of this study was to quantify soil CH4 and N2 O fluxes from smallholder agricultural systems on tropical peatlands in Southeast Asia and assess their environmental controls. The study was carried out in four regions in Malaysia and Indonesia. CH4 and N2 O fluxes and environmental parameters were measured in cropland, oil palm plantation, tree plantation and forest. Annual CH4 emissions (in kg CH4 ha-1 year-1 ) were: 70.7 ± 29.5, 2.1 ± 1.2, 2.1 ± 0.6 and 6.2 ± 1.9 at the forest, tree plantation, oil palm and cropland land-use classes, respectively. Annual N2 O emissions (in kg N2 O ha-1 year-1 ) were: 6.5 ± 2.8, 3.2 ± 1.2, 21.9 ± 11.4 and 33.6 ± 7.3 in the same order as above, respectively. Annual CH4 emissions were strongly determined by water table depth (WTD) and increased exponentially when annual WTD was above -25 cm. In contrast, annual N2 O emissions were strongly correlated with mean total dissolved nitrogen (TDN) in soil water, following a sigmoidal relationship, up to an apparent threshold of 10 mg N L-1 beyond which TDN seemingly ceased to be limiting for N2 O production. The new emissions data for CH4 and N2 O presented here should help to develop more robust country level 'emission factors' for the quantification of national GHG inventory reporting. The impact of TDN on N2 O emissions suggests that soil nutrient status strongly impacts emissions, and therefore, policies which reduce N-fertilisation inputs might contribute to emissions mitigation from agricultural peat landscapes. However, the most important policy intervention for reducing emissions is one that reduces the conversion of peat swamp forest to agriculture on peatlands in the first place.

Operative and Nonoperative Outcomes of Emergency General Surgery Conditions: An Observational Study Using a Novel Instrumental Variable.

OBJECTIVE: To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes. BACKGROUND: Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce. METHODS: We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions. RESULTS: For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter. CONCLUSIONS: The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.

The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania.

BACKGROUND: Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. METHODS: We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. RESULTS: In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. CONCLUSION: There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.

Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries.

BACKGROUND: Qualifying comorbidity sets (QCS) are tools used to identify multimorbid patients at increased surgical risk. It is unknown how the QCS framework for multimorbidity affects surgical risk in different racial groups. METHODS: This retrospective cohort study included Medicare patients age ≥65.5 who underwent an emergency general surgery operation from 2015 to 2018. Our exposure was race and multimorbidity, included in our model as an interaction term. The primary outcome of the study was 30-day mortality. Secondary outcomes included routine discharge, 30-day readmission, length of stay, and complications. RESULTS: In total, 163,148 patients who underwent and operation were included in this study. Of these, 13,852 (8.5%, p < 0.001) were Black, and 149,296 (91.5%, p < 0.001) were White. Black multimorbid patients had no significant differences in 30-day mortality, routine discharge or 30-day readmission when compared to White multimorbid patients after risk-adjustment. Black multimorbid patients had significantly lower odds of complications (OR 0.89, p = 0.014) compared to White multimorbid patients. CONCLUSIONS: Our study of universally insured patients highlights the critical role of pre-operative health status and its association with surgical outcomes.

Providing Remote Aid During a Humanitarian Crisis.

Humanitarian crises create opportunities for both in-person and remote aid. Durable, complex, and team-based care may leverage a telemedicine approach for comprehensive support within a conflict zone. Barriers and enablers are detailed, as is the need for mission expansion due to initial program success. Adapting a telemedicine program initially designed for critical care during the severe acute respiratory syndrome coronavirus 2 pandemic offers a solution to data transfer and data analysis issues. Staffing efforts and grouped elements of patient care detail the kinds of remote aid that are achievable. A multiprofessional team-based approach (clinical, administrative, nongovernmental organization, government) can provide comprehensive consultation addressing surgical planning, critical care management, infection and infection control management, and patient transfer for complex care. Operational and network security create parallel concerns relevant to avoid geolocation and network intrusion during consultation. Deliberate approaches to address cultural differences that influence relational dynamics are also essential for mission success.

A survey of organizational structure and operational practices of elite youth football academies and national federations from around the world: A performance and medical perspective.

Aim: Medical and performance units are integral components of player development programmes in elite football academies. Nevertheless, the nature of the operational processes implemented by practitioners within clubs and national federations remains unexplored. The aim of the present study, therefore, was to survey elite youth professional football academies from around the world regarding the operational processes adopted by their medical and performance units. Methods: Of the 50 organizations invited, 10 national federations and 25 clubs took part in the survey resulting in a response rate of 70% (95% confidence interval, 56%-81%). The respondents represented three groups: senior club and academy management, performance, and medical staff. Results: The majority (60%-90%) of clubs and national federations reported strategic alignment between senior and academy medical and performance units as well as between academy medical and performance units. Survey responses indicated substantial heterogeneity in the composition and number of medical and performance professionals employed in academies. The majority of respondents agreed their medical and performance departments were effective in utilizing staff knowledge and external sources of knowledge to inform their practice (56%-80%). Performance staff (40%-50%) and physiotherapists (30%-32%) were deemed most influential in injury prevention programmes. During the return-to-play process, the influence of specific practitioners in the medical and performance units was dependent upon the phase of return-to-play. Shared decision-making was common practice amongst performance and medical staff in injury prevention and return-to-play processes. Medical and performance data were generally centralized across the first team and academy in majority (50%-72%) of clubs and national federations. Data were integrated within the same data management system to a higher degree in clubs (68%) vs. national federations (40%). Research and development activity were reported for most academies (50%-72%), and generally led by the head of performance (37%) or team doctor (21%). Research activities were largely undertaken via internal staff (~100%), academic collaborations (50%-88%) and/or external consultants and industry partnerships (77%-83%) in the national federation and clubs. Conclusion: Collectively, these findings provide a detailed overview regarding key operational processes delivered by medical and performance practitioners working in elite football academies.

Rates of Surgical Consultations After Emergency Department Admission in Black and White Medicare Patients.

Importance: A surgical consultation is a critical first step in the care of patients with emergency general surgery conditions. It is unknown if Black Medicare patients and White Medicare patients receive surgical consultations at similar rates when they are admitted from the emergency department. Objective: To determine whether Black Medicare patients have similar rates of surgical consultations when compared with White Medicare patients after being admitted from the emergency department with an emergency general surgery condition. Design, Setting, and Participants: This was a retrospective cohort study that took place at US hospitals with an emergency department and used a computational generalization of inverse propensity score weight to create patient populations with similar covariate distributions. Participants were Medicare patients age 65.5 years or older admitted from the emergency department for an emergency general surgery condition between July 1, 2015, and June 30, 2018. The analysis was performed during February 2022. Patients were classified into 1 of 5 emergency general surgery condition categories based on principal diagnosis codes: colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, and upper gastrointestinal. Exposures: Black vs White race. Main Outcomes and Measures: Receipt of a surgical consultation after admission from the emergency department with an emergency general surgery condition. Results: A total of 1 686 940 patients were included in the study. Of those included, 214 788 patients were Black (12.7%) and 1 472 152 patients were White (87.3%). After standardizing for medical and diagnostic imaging covariates, Black patients had 14% lower odds of receiving a surgical consultation (odds ratio [OR], 0.86; 95% CI, 0.85-0.87) with a risk difference of -3.17 (95% CI, -3.41 to -2.92). After standardizing for socioeconomic covariates, Black patients remained at an 11% lower odds of receiving a surgical consultation compared with similar White patients (OR, 0.89; 95% CI, 0.88-0.90) with a risk difference of -2.49 (95% CI, -2.75 to -2.23). Additionally, when restricting the analysis to Black patients and White patients who were treated in the same hospitals, Black patients had 8% lower odds of receiving a surgical consultation when compared with White patients (OR, 0.92; 95% CI, 0.90-0.93) with a risk difference of -1.82 (95% CI, -2.18 to -1.46). Conclusions and Relevance: In this study, Black Medicare patients had lower odds of receiving a surgical consultation after being admitted from the emergency department with an emergency general surgery condition when compared with similar White Medicare patients. These disparities in consultation rates cannot be fully attributed to medical comorbidities, insurance status, socioeconomic factors, or individual hospital-level effects.

The contribution of Neanderthal introgression to modern human traits.

Neanderthals, our closest extinct relatives, lived in western Eurasia from 400,000 years ago until they went extinct around 40,000 years ago. DNA retrieved from ancient specimens revealed that Neanderthals mated with modern human contemporaries. As a consequence, introgressed Neanderthal DNA survives scattered across the human genome such that 1-4% of the genome of present-day people outside Africa are inherited from Neanderthal ancestors. Patterns of Neanderthal introgressed genomic sequences suggest that Neanderthal alleles had distinct fates in the modern human genetic background. Some Neanderthal alleles facilitated human adaptation to new environments such as novel climate conditions, UV exposure levels and pathogens, while others had deleterious consequences. Here, we review the body of work on Neanderthal introgression over the past decade. We describe how evolutionary forces shaped the genomic landscape of Neanderthal introgression and highlight the impact of introgressed alleles on human biology and phenotypic variation.

Association Between Geospatial Access to Care and Firearm Injury Mortality in Philadelphia.

Importance: The burden of firearm violence in US cities continues to rise. The role of access to trauma center care as a trauma system measure with implications for firearm injury mortality has not been comprehensively evaluated. Objective: To evaluate the association between geospatial access to care and firearm injury mortality in an urban trauma system. Design, Setting, and Participants: Retrospective cohort study of all people 15 years and older shot due to interpersonal violence in Philadelphia, Pennsylvania, between January 1, 2015, and August 9, 2021. Exposures: Geospatial access to care, defined as the predicted ground transport time to the nearest trauma center for each person shot, derived by geospatial network analysis. Main Outcomes and Measures: Risk-adjusted mortality estimated using hierarchical logistic regression. The population attributable fraction was used to estimate the proportion of fatalities attributable to disparities in geospatial access to care. Results: During the study period, 10 105 people (910 [9%] female and 9195 [91%] male; median [IQR] age, 26 [21-28] years; 8441 [84%] Black, 1596 [16%] White, and 68 other [<1%], including Asian and unknown, consolidated owing to small numbers) were shot due to interpersonal violence in Philadelphia. Of these, 1999 (20%) died. The median (IQR) predicted transport time was 5.6 (3.8-7.2) minutes. After risk adjustment, each additional minute of predicted ground transport time was associated with an increase in odds of mortality (odds ratio [OR], 1.03 per minute; 95% CI, 1.01-1.05). Calculation of the population attributable fraction using mortality rate ratios for incremental 1-minute increases in predicted ground transport time estimated that 23% of shooting fatalities could be attributed to differences in access to care, equivalent to 455 deaths over the study period. Conclusions and Relevance: These findings indicate that geospatial access to care may be an important trauma system measure, improvements to which may result in reduced deaths from gun violence in US cities.

Developing and leading a sustainable organization for early career acute care surgeons: Lessons from the inaugural American Association for the Surgery of Trauma Associate Member Council.

ABSTRACT: The associate membership of the American Association for the Surgery of Trauma (AAST) was established in 2019 to create a defined but incorporated entity within the larger AAST for the next generation of acute care surgeons. The Associate Member Council (AMC) was subsequently established in 2020 to provide the new AM with an elected group of leaders who would represent them within the AAST. In its inaugural year, this cohort of junior faculty and surgical trainees had developed for the AM a set of bylaws, a mission statement, a strategic vision, and a succession plan. The experience of the AAST AMC is exemplary of what can be accomplished with collaboration, mentorship, innovation, and tenacity. It has the potential to serve as a template for the creation and vitalization of future professional groups. In this piece, the AMC proposes a blueprint for the successful conception of a new organization.

What happens after they survive? The role of anticoagulants and antiplatelets in IVC injuries.

Background: Venous thromboembolism (VTE) after an inferior vena cava (IVC) injury is a devastating complication. Current practice involves variable use of anticoagulation and antiplatelet (AC/AP) agents. We hypothesized that AC/AP can reduce the incidence of VTE and that delayed institution of AC/AP is associated with increased VTE events. Methods: We retrospectively reviewed IVC injuries cared for at a large urban adult academic level 1 trauma center between January 1, 2008 and December 31, 2020, surviving 72 hours. Patient demographics, injury mechanism, surgical repair, type and timing of AC, and type and timing of VTE events were characterized. Postoperative AC status during hospital course before an acute VTE event was delineated by grouping patients into four categories: full, prophylactic, prophylactic with concomitant AP, and none. The primary outcome was the incidence of an acute VTE event. IVC ligation was excluded from analysis. Results: Of the 76 patients sustaining an IVC injury, 26 were included. The incidence of a new deep vein thrombosis distal to the IVC injury and a new pulmonary embolism was 31% and 15%, respectively. The median onset of VTE was 5 days (IQR 1-11). Four received full AC, 10 received prophylactic AC with concomitant AP, 8 received prophylactic AC, and 4 received no AC/AP. New VTE events occurred in 0.0% of full, in 30.0% of prophylactic with concomitant AP, in 50.0% of prophylactic, and in 50.0% without AC/AP. There was no difference in baseline demographics, injury mechanisms, surgical interventions, and bleeding complications. Discussion: This is the first study to suggest that delay and degree of antithrombotic initiation in an IVC-injured patient may be associated with an increase in VTE events. Consideration of therapy initiation should be performed on hemostatic stabilization. Future studies are necessary to characterize the optimal dosing and temporal timing of these therapies. Level of evidence: Therapeutic, level 3.

Change in outcomes for trauma patients over time: Two decades of a state trauma system.

BACKGROUND: Trauma center mortality rates are benchmarked to expected rates of death based on patient and injury characteristics. The expected mortality rate is recalculated from pooled outcomes across a trauma system each year, obscuring system-level change across years. We hypothesized that risk-adjusted mortality would decrease over time within a state-wide trauma system. METHODS: We identified adult trauma patients presenting to Level I and II Pennsylvania trauma centers, 1999-2018, using the Pennsylvania Trauma Outcomes Study. Multivariable logistic regression generated risk-adjusted models for mortality in all patients, and in key subgroups: penetrating torso injury, blunt multisystem trauma, and patients presenting in shock. RESULTS: Of 162,646 included patients, 123,518 (76.1%) were white and 108,936 (67.0%) were male. The median age was 49 (interquartile range [IQR] 29-70), median injury severity score was 16 (IQR 10-24), and 87.5% of injuries were blunt. Overall, 9.9% of patients died, and compared to 1999, no year had significantly higher adjusted odds of mortality. Overall mortality was significantly lower in 2007-2009 and 2011-2018. Of patients with blunt, multisystem injuries, 17.7% died, and adjusted mortality improved over time. Mortality rates were 24.9% for penetrating torso injury, and 56.9% for shock, with no significant change. Mortality improved for patients with ISS < 25, but not for the most severely injured. CONCLUSIONS: Over 20 years, Pennsylvania trauma centers demonstrated improved risk-adjusted mortality rates overall, but improvement remains lacking in high-risk groups despite numerous innovations and practice changes in this time period. Identifying change over time can help guide focus to these critical gaps.

Beyond pain and disability: The lasting effects of trauma on life after injury.

BACKGROUND: The impact of traumatic injury likely extends beyond direct physical consequences and lasts well beyond the acute injury phase. Data collection is sparse after hospital discharge, however. In this observational study, we hypothesized that sequelae of injury would last at least 6 months and sought to prospectively determine patient-reported physical, emotional, and social outcomes during this postinjury period. METHODS: We surveyed patients admitted to our Level I trauma center (July 2019 to October 2020) regarding baseline functioning and quality of life after injury, using the Patient-Reported Outcomes Measurement Information System (PROMIS-29) instrument, a primary care posttraumatic stress disorder screen, and questions on substance use, employment, and living situation. Patients were re-surveyed at 6 months. PROMIS-29 scores are reported as t scores compared with the US population. Differences between groups were analyzed using χ 2 , signed-rank, and t tests, with paired tests used for changes over time. RESULTS: Three hundred sixty-two patients completed the baseline, 130 of whom completed 6-month follow-up. Those completing the 6-month survey were similar ages (43.3 ± 17.8 vs. 44.4 ± 19.0, p = 0.57), mechanism (24.7% vs. 28.0% shot or stabbed, p = 0.61), and severities (median Injury Severity Score, 9 vs. 9; p = 0.15) as those who only completed the baseline. There were 55.0% reported being hospitalized for an injury previously. Patients reported decreases in ability to participate in social roles and activities (mean t score 51.4 vs. 55.3; p = 0.011) and increases in anxiety (53.8 vs. 50.5, p = 0.011) and depression (51.0 vs. 48.7, p = 0.025). There were 26.2% that screened positive for posttraumatic stress disorder at 6 months. Employment decreased at 6 months, with 63.9% reporting being "occasionally" employed or unemployed at 6 months versus 44.6% preinjury ( p < 0.001). CONCLUSION: The effects of injury extend beyond pain and disability, impacting several realms of life for at least 6 months following trauma. These data support the development of screening and intervention protocols for postinjury patients. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.