Early Abnormal Vital Signs Predict Poor Outcomes in Normotensive Patients Following Penetrating Trauma.

INTRODUCTION: Because trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma. METHODS: A retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann-Whitney tests, and regression analyses were performed as appropriate. RESULTS: We identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not. CONCLUSIONS: Immediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma.

Multiple Casualty Incidents at a Level I Trauma Center: A 15-year Analysis.

INTRODUCTION: Limited evidence regarding multiple casualty outcomes exists. Given resource strain with increasing patient load, we hypothesized that patients involved in a multiple casualty incident have worse outcomes compared to standard trauma patients. METHODS: Multiple casualty victims from 2006 to 2021 at our institution were identified; admission data and trauma outcomes were then compared to standard trauma patients. Chi-square tests and Mann-Whitney U-tests were performed for categorical and non-normal continuous data, respectively. Logistic regression was performed to evaluate associations with mortality and intensive care unit (ICU) admission. RESULTS: We identified 39,924 patients, of which 612 were multiple casualty patients (1.5%). Multiple casualty involvement was associated with younger age (29 y versus 44 y, P < 0.001) and higher rates of penetrating trauma (26.1% versus 21.4%; P < 0.001). Multiple casualty involvement was associated with higher injury severity score (ISS) (11.6 versus 7.9, P < 0.001), mortality (2.4% versus 1.5% P < 0.005), and ICU admission (17% versus 13%, P < 0.005). On logistic regression analysis, age, ISS, shock index, presence of the COVID-19 pandemic, and mechanism all independently predicted mortality (P ≤ 0.003), while multiple casualty involvement did not (P = 0.302). CONCLUSIONS: Although multiple casualty incidents are associated with patient factors that increase hospital resource strain, when controlling for age, ISS, shock index, presence of the COVID-19 pandemic, and trauma mechanism, involvement in multiple casualty incident was not independently associated with ICU admission or mortality. Improved understanding of the impact of high-volume trauma may allow us to improve our care of this at-risk population.

Impact of safety-net hospital burden on achievement of textbook oncologic outcomes following resection in for stage I-IV colorectal cancer.

BACKGROUND AND OBJECTIVES: Textbook oncologic outcome (TOO) is a benchmark for high-quality surgical cancer care but has not been studied at safety-net hospitals (SNH). The study sought to understand how SNH burden affects TOO achievement in colorectal cancer. METHODS: The National Cancer Database was queried for colorectal cancer patients who underwent resection for stage I-III plus stage IV with liver-only metastases (2010-2019). TOO was defined as R0 resection, AJCC-compliant lymphadenectomy (>12 nodes), no prolonged LOS, no 30-day mortality/readmission, and receipt of stage-appropriate adjuvant chemotherapy. RESULTS: Of 487,195 patients, 66.7% achieved TOO. Lower achievement was explained by adequate lymphadenectomy (87.3%), non-prolonged LOS (76.3%), and receipt of adjuvant chemotherapy in stage III (60.3%) and IV (54.1%). Treatment at high burden hospitals (HBH, >10% Medicaid/uninsured) was a predictor of non-TOO (Stage I/II: OR 0.83, III: OR 0.86, IV: OR 0.83; all p < 0.001). Achieving TOO was associated with decreased mortality (Stage I/II: HR 0.49, III: HR 0.48, IV: HR 0.57; all p < 0.001), and HBH treatment was a predictor of mortality (Stage I/II: HR 1.09, III: HR 1.05, IV: HR 1.07; all p < 0.05). CONCLUSIONS: Treatment at higher SNH burden hospitals was associated with less frequent TOO achievement and increased mortality. Quality improvement targets include receipt of adjuvant chemotherapy and avoidance of prolonged LOS.

Cost-effectiveness analysis of routine computed tomography angiography (CTA) for lower extremity penetrating trauma.

BACKGROUND: Routine evaluation with CTA for patients with isolated lower extremity penetrating trauma and normal ankle-brachial-indices (ABI) remains controversial. While prior literature has found normal ABI's (≥0.9) and a normal clinical examination to be adequate for safe discharge, there remains concern for missed injuries which could lead to delayed surgical intervention and unnecessary morbidity. Our hypothesis was that routine CTA after isolated lower extremity penetrating trauma with normal ABIs and clinical examination is not cost-effective. METHODS: We performed a decision-analytic model to evaluate the cost-effectiveness of obtaining a CTA routinely compared to clinical observation and ABI evaluation in hemodynamically normal patients with isolated penetrating lower extremity trauma. Our base case was a patient that sustained penetrating lower extremity trauma with normal ABIs that received a CTA in the trauma bay. Costs, probability, and Quality-Adjusted Life Years (QALYs) were generated from published literature. RESULTS: Clinical evaluation only (no CTA) was cost-effective with a cost of $2056.13 and 0.98 QALYs gained compared to routine CTA which had increased costs of $7449.91 and lower QALYs 0.92. Using one-way sensitivity analysis, routine CTA does not become the cost-effective strategy until the cost of a missed injury reaches $210,075.83. CONCLUSIONS: Patients with isolated, penetrating lower extremity trauma with normal ABIs and clinical examination do not warrant routine CTA as there is no benefit with increased costs.

Shift in Prehospital Mode of Transportation for Trauma Patients During the COVID-19 Pandemic.

INTRODUCTION: Since the start of the COVID-19 pandemic, we experienced alterations to modes of transportation among trauma patients suffering penetrating injuries. Historically, a small percentage of our penetrating trauma patients use private means of prehospital transportation. Our hypothesis was that the use of private transportation among trauma patients increased during the COVID-19 pandemic and was associated with better outcomes. METHODS: We retrospectively reviewed all adult trauma patients (January 1, 2017 to March 19, 2021), using the date of the shelter-in-place ordinance (March 19, 2020) to separate trauma patients into prepandemic and pandemic patient groups. Patient demographics, mechanism of injury, mode of prehospital transportation, and variables such as initial Injury Severity Score, Intensive Care Unit (ICU) admission, ICU length of stay, mechanical ventilator days, and mortality were recorded. RESULTS: We identified 11,919 adult trauma patients, 9017 (75.7%) in the prepandemic group and 2902 (24.3%) in the pandemic group. The number of patients using private prehospital transportation also increased (from 2.4% to 6.7%, P < 0.001). Between the prepandemic and pandemic private transportation cohorts, there were reductions in mean Injury Severity Score (from 8.1 ± 10.4 to 5.3 ± 6.6: P = 0.02), ICU admission rates (from 15% to 2.4%: P < 0.001), and hospital length of stay (from 4.0 ± 5.3 to 2.3 ± 1.9: P = 0.02). However, there was no difference in mortality (4.1% and 2.0%, P = 0.221). CONCLUSIONS: We found that there was a significant shift in prehospital transportation among trauma patients toward private transportation after the shelter-in-place order. However, this did not coincide with a change in mortality despite a downward trend. This phenomenon could help direct future policy and protocols in trauma systems when battling major public health emergencies.

Racial Disparities Among Trauma Patients During the COVID-19 Pandemic.

INTRODUCTION: Given the disparate effects of the COVID-19 pandemic on people of color, we hypothesized that patients of color experienced a disproportionate increase in trauma during the COVID-19 pandemic. MATERIALS AND METHODS: We compared trauma patients arriving in the 3 y before our statewide stay-at-home mandate on March 20, 2020 (PRE) to those arriving in the year afterward (POST). In addition to race/ethnicity, we assessed patient demographics and other clinical variables. Chi-squared, Fisher's exact, and Mann-Whitney U tests were used for univariate analyses. A multivariable logistic regression was performed to assess for associations with mortality. RESULTS: During the study period, 8583 patients were included in the PRE group and 2883 were included in the POST group. There were increases in penetrating trauma (PRE 14.7%, POST 23.1%; P < 0.001) and mortality rates (PRE 3.20%, POST 4.60%; P < 0.001). From PRE to POST, the percentage of Black patients increased from 35.0% to 38.3% (P = 0.01) and the percentage of Hispanic patients increased from 19.2% to 23.0% (P < 0.001). After a multivariable analysis, Asian patients experienced an independent increase in mortality from PRE to POST (odds ratio 2.00, 95% confidence interval 1.13-3.54, P = 0.02). CONCLUSIONS: Penetrating trauma and mortality rates increased during the pandemic. There was a simultaneous increase in the percentage of Black and Hispanic trauma patients. Asian patient mortality increased significantly after the start of the pandemic independent of other variables. Identifying racial/ethnic disparities is the first step in finding ways to improve dissimilar outcomes.

Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces.

BACKGROUND: Traumatic pneumothorax management has evolved to include the use of smaller caliber tube thoracostomy and even observation alone. Data is limited comparing tube thoracostomy to observation for small traumatic pneumothoraces. We aimed to investigate whether observing patients with a small traumatic pneumothorax on initial chest radiograph (CXR) is associated with improved outcomes compared to tube thoracostomy. METHODS: We retrospectively reviewed trauma patients at our level 1 trauma center from January 1, 2016 through December 31, 2020. We included those with a pneumothorax size <30 mm as measured from apex to cupola on initial CXR. We excluded patients with injury severity score ≥ 25, operative requirements, hemothorax, bilateral pneumothoraces, and intensive care unit admission. Patients were grouped by management strategy (observation vs tube thoracostomy). Our primary outcome was length of stay with secondary outcomes of pulmonary infection, failed trial of observation, readmission, and mortality. Results are listed as mean ± standard error of the mean. RESULTS: Of patients who met criteria, 39 were in the observation group, and 34 were in the tube thoracostomy group. Baseline characteristics were similar between the groups. Average pneumothorax size on CXR was 18 ± 1.0 mm in the observation group and 18 ± 0.84 mm in the tube thoracostomy group (p > 0.99). Average pneumothorax sizes on computed tomography were 25 ± 2.1 and 37 ± 3.9 mm in the observation and tube thoracostomy groups, respectively (p = 0.01). Length of stay in the observation group was significantly shorter than the tube thoracostomy group (3.6 ± 0.33 vs 5.8 ± 0.81 days, p < 0.01). While pneumothorax size on computed tomography was associated with tube thoracostomy, only tube thoracostomy correlated with length of stay on multivariable analysis; pneumothorax size on CXR and computed tomography did not. There were no deaths or readmissions in either cohort. One patient in the observation group required tube thoracostomy after 18 h for worsening subcutaneous emphysema, and one patient in the tube thoracostomy group developed an empyema. CONCLUSIONS: Select patients with small traumatic pneumothoraces on initial chest radiograph who were treated with observation experienced an average length of stay over two days shorter than those treated with tube thoracostomy. Outcomes were otherwise similar between the two groups suggesting that an observation-first strategy may be a superior treatment approach for these patients.

Differences in clinical characteristics and outcomes for blunt versus penetrating traumatic pulmonary pseudocysts.

INTRODUCTION: Traumatic pulmonary pseudocysts (TPPs) are under-reported in blunt trauma and rarely reported in penetrating trauma. Little is known about the impact of injury mechanism on the pathophysiology or the risk factors that predispose to worse patient outcomes. We hypothesized that blunt and penetrating TPPs have different clinical characteristics and outcomes. METHODS: Computed tomography imaging was evaluated for patients presenting at a level 1 trauma center with confirmed TPP from 2011 to 2018. Diameter was determined by largest dimension of the dominant TPP. Clinical variables and TPP features were compared for blunt versus penetrating trauma by using comparative statistics and multivariable analysis.e RESULTS: A total of 101 TPP patients were identified (blunt = 64; penetrating = 37). In penetrating TPP, rates of concomitant pulmonary laceration, hemothorax, and pneumothorax, were, respectively, 4.5, 3.1, and 1.4 times higher than for blunt TPP. Concomitant rib fracture was twice as common in blunt TPP as in penetrating TPP (69% versus 32%). For penetrating injury, the risk of complications related to TPP was increased (aOR = 5.3), specifically persistent/recurrent pneumothorax (aOR = 10.4). All deaths resulted from pulmonary hemorrhage (blunt = 3, penetrating = 2). Regardless of mechanism, air-fluid level and hemoptysis correlated with death (p < 0.02) and all patients with hemoptysis required pulmonary intervention (p = 0.0001). CONCLUSION: Penetrating TPPs demonstrate a unique pattern of concurrent lung injury and increased complication risk. Importantly, severe hemoptysis and air-fluid level may indicate risk of impending morbidity and mortality regardless of injury mechanism and should serve as an early warning sign for the trauma physician.

Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis.

BACKGROUND: Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT. METHODS: A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project. RESULTS: In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model. CONCLUSIONS: ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

Routine Repeat Head CT Does Not Change Management in Trauma Patients on Novel Anticoagulants.

INTRODUCTION: Guidelines for imaging anticoagulated patients following a traumatic injury are unclear. Interval CT head (CTH) is often routinely performed after initial negative CTH to assess for delayed intracranial hemorrhage (ICH-d). The rate of ICH-d for patients taking novel oral anticoagulants (NOACs) is unknown. We hypothesized that the incidence of ICH-d in patients on NOACs would be similar, if not lower to that of warfarin, and routine repeat CTH after initial negative would not change management, and thus, may not be indicated. MATERIALS AND METHODS: Anticoagulated patients presenting with blunt trauma to a level I trauma center between 2016 and 2018 were evaluated. Exclusion criteria included: positive initial CTH and those taking nonoral anticoagulation or antiplatelet agents alone (without warfarin or NOAC). Outcomes included: ICH-d, discharge GCS, administration of reversal agents, neurosurgical intervention, readmission, and death. Multivariable regression was performed to evaluate patient factors associated with the development of ICH-d. RESULTS: A total of 332 patients met the inclusion criteria. Patients were divided into a warfarin group (n = 191) and NOAC group (n = 141). The incidence of ICH-d in the warfarin group was 2.6% (5/191) and 2.1% (3/141) in the NOAC group (P = 0.77). There were no reversal agents administered, neurosurgical interventions, readmissions, or deaths in the NOAC group. CONCLUSIONS: Little is known about the impact of NOACs in the setting of trauma, especially regarding risks of ICH-d following traumatic injury. In the NOAC group, ICH-d occurred only 2.1% of the time. In addition, there were no reversal agents given, neurosurgical interventions, or deaths. These data, taken together, suggest the limited utility of repeat imaging in this patient population.

Protective Effect of Phosphatidylserine Blockade in Hemorrhagic Shock.

BACKGROUND: Phosphatidylserine (PS) is a key cell membrane phospholipid normally maintained on the inner cell surface but externalizes to the outer surface in response to cellular stress. We hypothesized that PS exposure mediates organ dysfunction in hemorrhagic shock. Our aims were to evaluate PS blockade on (1) pulmonary, (2) renal, and (3) gut function, as well as (4) serum lysophosphatidic acid (LPA), an inflammatory mediator generated by PS externalization, as a possible mechanism mediating organ dysfunction. MATERIALS AND METHODS: Rats were either (1) monitored for 130 min (controls, n = 3), (2) hemorrhaged then resuscitated (hemorrhage only group, n = 3), or (3) treated with Diannexin (DA), a PS blocking agent, followed by hemorrhage and resuscitation (DA + hemorrhage group, n = 4). Pulmonary dysfunction was assessed by arterial partial pressure of oxygen, renal dysfunction by serum creatinine, and gut dysfunction by mesenteric endothelial permeability (LP). LPA levels were measured in all groups. RESULTS: Pulmonary: there was no difference in arterial partial pressure of oxygen between groups. Renal: after resuscitation, creatinine levels were lower after PS blockade with DA versus hemorrhage only group (P = 0.01). Gut: LP was decreased after PS blockade with DA versus hemorrhage only group (P < 0.01). Finally, LPA levels were also lower after PS blockade with DA versus the hemorrhage only group but higher than the control group (P < 0.01). CONCLUSIONS: PS blockade with DA decreased renal and gut dysfunction associated with hemorrhagic shock and attenuated the magnitude of LPA generation. Our findings suggest potential for therapeutic targets in the future that could prevent organ dysfunction associated with hemorrhagic shock.

Automatic acoustic gunshot sensor technology's impact on trauma care.

INTRODUCTION: As cities nation-wide combat gun violence, with less than 20% of shots fired reported to police, use of acoustic gunshot sensor (AGS) technology is increasingly common. However, there are no studies to date investigating whether these technologies affect outcomes for victims of gunshot wounds (GSW). We hypothesized that the AGS technology would be associated with decreased prehospital transport time. METHODS: All GSW patients from 2014 to 2016 were collected from our institutional registry and cross-referenced with local police department data regarding times and locations of AGS alerts. Each GSW incident was categorized as related or unrelated to an AGS alert. Admission data, trauma outcomes, and prehospital time were then compared. RESULTS: We analyzed 731 patients. Of these, 192 were AGS-related (26%) and 539 were not (74%). AGS-related patients were more likely to be female (p < 0.01), have a higher injury severity score (ISS) (p < 0.01), and require an operation (p = 0.03). Ventilator days (p < 0.05) and hospital length of stay (p < 0.01) was greater in the AGS cohort. Mortality, however, did not differ between groups (p = 0.5). On multivariable analysis, both total prehospital time and on-scene time were lower in the AGS group (p < 0.01). CONCLUSION: Our study suggests reduced transport times, decreased prehospital and emergency medical service on-scene times with AGS technology. Additionally, despite higher ISS and use of more hospital resources, mortality was similar to non-AGS counterparts. The potential of AGS technology to further decrease prehospital times in the urban setting may provide an opportunity to improve outcomes in trauma patients with penetrating injuries.

Repeat computed tomography is highly sensitive in determining need for delayed exploration in blunt abdominal trauma.

BACKGROUND: Computed tomography (CT) imaging has an established role in the initial evaluation of blunt abdominal trauma. What is less clear is the role of CT in guiding delayed exploration in patients initially managed nonoperatively after blunt trauma. We hypothesized that a repeat CT would accurately identify the need for an exploratory laparotomy in this patient population. MATERIALS AND METHODS: From 2005 to 2014, we reviewed all blunt abdominal trauma patients at our institution who received an admission CT scan. We identified patients who underwent repeat CT of the abdomen within 72 h for the documented purpose of reevaluating potential intra-abdominal injuries. CT findings were categorized as either having a CT indication for exploration or not, allowing a sensitivity analysis. RESULTS: Of the 50 patients who met our inclusion criteria, 9 underwent surgical exploration of the abdomen and 41 did not. Admission clinical indicators such as Glasgow Coma Scale, Injury Severity Score, and vitals were similar between the operative and nonoperative groups (P > 0.05). When compared with initial CT scan, repeat scan was found to increase the sensitivity from 67% to 100%, while also improving the specificity to 86%, positive predictive value to 50%, and negative predictive value to 100%. CONCLUSIONS: Repeat CT scan of the abdomen may be useful in evaluating blunt trauma patients initially managed nonoperatively. The second CT scan increases the sensitivity of CT evaluation to 100% while also improving the specificity, positive predictive value, and negative predictive value.

Shedding new light on rapidly resolving traumatic acute subdural hematomas.

BACKGROUND: Rapidly resolving acute subdural hematomas (RRASDHs) have been described in case reports and case series but are still poorly understood. We hypothesized that a cohort analysis would confirm previously reported predictors of RRASDH including coagulopathy, additional intracranial hemorrhage, and low-density band on imaging. We also hypothesized that rapid resolution would be associated with improved trauma outcomes. METHODS: We reviewed all nonoperative acute subdural hematomas (ASDHs) treated at our center from 2011 to 2015. Inclusion criteria were ASDH on computed tomography (CT), admission Glasgow coma score >7, and repeat CT to evaluate ASDH change. RRASDH was defined as reduced hematoma thickness by 50% within 72 h. Clinical data, CT findings, and trauma end points were analyzed for the RRASDH and nonresolving groups. RESULTS: There were 154 ASDH patients included, with 29 cases of RRASDH. The RRASDH group had a lower rate of comorbidities than the nonresolving group (58.6% versus 78.4%, P = 0.03) and a lower rate of prehospital anticoagulation (7.7% versus 37.1%, P = 0.004). Previously reported predictors of RRASDH did not differ between the groups, nor did any clinical outcome measures. When compared with patients who experienced rapid growth (>50% increased width in 72 h), the RRASDH group had lower mortality (3.4% versus 23.5%, P = 0.04). CONCLUSIONS: To our knowledge, this is the largest review of RRASDHs. We identified two previously unrecognized factors that may predict resolution; however, previously reported predictors were not associated with resolution. We also found no relationship between RRASDHs and improved standard trauma outcomes, calling into question the clinical significance of RRASDH.

Lactate predicts massive transfusion in hemodynamically normal patients.

BACKGROUND: Trauma patients at risk of deterioration because of occult injury may be hemodynamically normal on arrival. Early identification of these patients may improve care, especially for those who require massive transfusion (MT). We hypothesized that elevated admission lactate would predict the need for MT in hemodynamically normal patients. MATERIALS AND METHODS: All trauma patients treated at our university-based urban center over a 5-year period were reviewed. We included hemodynamically normal patients who had an admission lactate performed. First, a receiver-operating curve was used to determine the threshold lactate value. Subsequent analyses were then based on this value. Variables were analyzed using chi-square and unpaired t-tests, and univariable and multivariable regressions. RESULTS: There were 3468 hemodynamically normal patients with an admission lactate. Those who received MT (n = 19) had higher lactate than those who did not (n = 3449; 5.6 versus 2.6 mmol/L, P ≤ 0.001). Receiver-operating curve curve analysis revealed a threshold lactate value of 4 mmol/L with an area under the curve of 0.71. Patients with a lactate of >4 mmol/L had increased mortality (8% versus 2%), longer hospital length of stay (LOS, 6 versus 3 days), longer intensive care unit (ICU) LOS (6 versus 3 days), greater need for MT (2.8% versus 0.3%), and greater blood requirement (219 versus 38 mL; all P values < 0.001). After controlling for confounding variables, the predictive value of admission lactate >4 remained strong (odds ratio, 5.2; 95% confidence interval, 1.87-14.2). CONCLUSIONS: In hemodynamically normal trauma patients, the admission lactate of >4 mmol/L is a robust predictor of MT requirement and associated with poor outcomes.

Neighborhood socioeconomic status is associated with violent reinjury.

BACKGROUND: Measures of individual socioeconomic status correlate with recurrent violent injury; however, neighborhood socioeconomic status may also matter. We conducted a review of victims of interpersonal violence treated at our trauma center, hypothesizing that the percent of the population living under the poverty level in their neighborhood is associated with recurrent violent victimization. MATERIALS AND METHODS: We identified victims of interpersonal violence, ages 12-24, in our trauma registry from 2005-2010. Recurrent episodes of violent injury were identified through 2012. The percentage of the population living under the poverty level for the patient's zip code of residence was derived from United States census estimates and divided into quartiles. Multivariable logistic regression was conducted to evaluate predictors of violent injury recidivism. RESULTS: Our cohort consisted of 1890 patients. Multivariable logistic regression confirmed the following factors as independent predictors of violent injury recidivism: male sex (odds ratio [OR] = 2 [1.06-3.80]; P = 0.03), black race (OR = 2.1 [1.44-3.06]; P < 0.001), injury due to firearms (OR = 1.67 [1.12-2.50]; P = 0.01), and living in the lowest zip code socioeconomic quartile (OR = 1.59 [1.12-2.25]; P = 0.01). CONCLUSIONS: For young patients injured by violence, the socioeconomic position of their neighborhood of residence is independently correlated with their risk of violent reinjury. Low neighborhood socioeconomic status may be associated with a disrupted sense of safety after injury and also may alter a person's likelihood of engaging in behaviors correlated with recurrent violent injury. Programs aimed at reducing violent injury recidivism should address needs at the individual and neighborhood level.

Potential disparities in trauma: the undocumented Latino immigrant.

BACKGROUND: Little is known about the quality of trauma care undocumented immigrants receive. Documentation status may serve as a risk factor for health disparities. We hypothesized that undocumented Latino immigrants have an increased risk of mortality after trauma compared with Latinos with legal residence. MATERIALS AND METHODS: The medical records for Latino trauma patients at our university-based trauma center between 2007 and 2012 were retrospectively reviewed. Undocumented status was defined using two criteria: (1) lack of social security number and (2) insurance status as either "county," the local program that covers undocumented immigrants, or "self pay". Regression models were used to estimate the comparable risks of in-hospital mortality. RESULTS: Out of 2441 Latino trauma patients treated at our institution during the study period, 465 were undocumented. Latinos with legal residence and undocumented Latinos did not differ with regard to in-hospital mortality (3.4% versus 3.9%, respectively; P = 0.61). We found no association between documentation status and in-hospital mortality after trauma (odds ratio = 1.12 [0.43, 2.9]; P = 0.81). The independent predictors of in-hospital mortality included age, injury severity score, penetrating mechanism, and lack of private insurance but not documentation status. CONCLUSIONS: Undocumented Latino immigrants did not have an increased risk of in-hospital mortality after trauma; however, being uninsured was associated with a higher risk of death after trauma. For Latinos, we found no disparities based on immigration status for mortality after trauma, though disparities based on insurance status continue to persist.

Applying peripheral vascular injury guidelines to penetrating trauma.

INTRODUCTION: Treatment of traumatic vascular injury is evolving because of endovascular therapies. National guidelines advocate for embolization of injuries to lower extremity branch vessels, including pseudoaneurysms or arteriovenous fistulas, in hemodynamically normal patients without hard signs of vascular injury. However, patient stability and injury type may limit endovascular applicability at some centers. We hypothesized that for penetrating trauma, indications for endovascular treatment of peripheral vascular injuries, as outlined by national guidelines, are infrequent. METHODS: We reviewed records of patients sustaining penetrating peripheral vascular injuries treated at our university-based urban trauma center from 2006-2010. Patient demographics and outcomes were analyzed. RESULTS: In 92 patients with penetrating peripheral vascular injuries, 82 were managed operatively and 10 were managed nonoperatively. Seventeen (18%) were hemodynamically unstable on arrival, 44 (48%) had multiple vessels injured, and 76 (83%) presented at night and/or on the weekend. No pseudoaneurysms or arteriovenous fistulas were seen initially or at follow-up. Applying national guidelines to our cohort, only two patients (2.2%) met recommended criteria for endovascular treatment. CONCLUSIONS: According to national guidelines, indications for endovascular treatment of penetrating peripheral vascular injury are infrequent. Nearly two-thirds of patients with penetrating peripheral vascular injuries were hemodynamically unstable or had multiple vessels injured, making endovascular repair less desirable. Additionally, over 80% presented at night and/or on the weekend, which could delay treatment at some centers due to mobilization of the endovascular team. Trauma centers need to consider their resources when incorporating national guidelines in their treatment algorithms of penetrating vascular trauma.

Surgical Cancer Care in Safety-Net Hospitals: a Systematic Review.

BACKGROUND: Tertiary medical centers in the USA provide specialized, high-volume surgical cancer care, contributing standards for quality and outcomes. For the most vulnerable populations, safety-net hospitals (SNHs) remain the predominant provider of both complex and routine healthcare needs. The objective of this study was to evaluate access to and quality of surgical oncology care within SNHs. METHODS: A comprehensive and systematic review of the literature was conducted using PubMed, EMBASE, and Cochrane Library databases to identify all studies (January 2000-October 2021) reporting the delivery of surgical cancer care at SNHs in the USA (PROSPERO #CRD42021290092). These studies describe the process and/or outcomes of surgical care for gastrointestinal, hepatopancreatobiliary, or breast cancer patients seeking treatment at SNHs. RESULTS: Of 3753 records, 37 studies met the inclusion criteria. Surgical care for breast cancer (43%) was the most represented, followed by colorectal (30%) and hepatopancreatobiliary (16%) cancers. Financial constraints, cultural and language barriers, and limitations to insurance coverage were cited as common reasons for disparities in care within SNHs. Advanced disease at presentation was common among cancer patients seeking care at SNHs (range, 24-61% of patients). Though reports comparing cancer survival between SNHs and non-SNHs were few, results were mixed, underscoring the variability in care seen across SNHs. CONCLUSIONS: These findings highlight barriers in care facing many cancer patients. Continued efforts should address improving both access and quality of care for SNH patients. Future models include a transition away from a two-tiered system of resourced and under-resourced hospitals toward an integrated cancer system.

Does gastric volume in trauma patients identify a population at risk for developing pneumonia and poor outcomes?

BACKGROUND: Trauma patients may have full stomachs or impaired airway reflexes that place them at risk for aspiration and pneumonia. Our hypothesis was that trauma patients with larger gastric volumes as measured by abdominal computed tomography (CT) at admission have higher rates of pneumonia and worse outcomes. METHODS: We matched an initial cohort of 81 trauma patients with an admission CT of the abdomen and a diagnosis of pneumonia by Injury Severity Score and Abbreviated Injury Score of the head and chest with a control group of 81 trauma patients without pneumonia. We estimated gastric volumes on CT and compared variables using chi-square, t-tests, receiver operating curve analysis, and regression analysis. RESULTS: Patients with pneumonia had larger gastric volumes than those without pneumonia (879 cm(3)versus 704 cm(3); P = 0.04). Receiver operating curve analysis gave a gastric volume threshold value of 700 cm(3) as a predictor of pneumonia. Patients with a gastric volume ≥ 700 cm(3) had more pneumonia (61% versus 41%; P = 0.01), stayed longer in the hospital (27.6 versus 19.7 d; P < 0.05) and the intensive care unit (18.4 versus 12.5 d; P = 0.01), required more days on the ventilator (18.1 versus 12.0 d; P = 0.02), and had a trend toward increased mortality (17% versus 11%; P = 0.2). On multivariate analysis, nasogastric or orogastric tube (odds ratio 3.0; P = 0.004) and gastric volume >700 cm(3) (odds ratio 2.7; P = 0.004) were independent predictors of pneumonia. CONCLUSIONS: Trauma patients who developed pneumonia had larger initial gastric volumes. A straightforward estimate of gastric volume on admission abdominal CT may predict patients at risk for developing pneumonia and poor outcomes. Clinicians should be especially vigilant in taking precautions against pneumonia and have a lower threshold for suspecting pneumonia in patients with abdominal CT gastric volumes ≥ 700 cm(3).