Mangled Lower Extremity Is Associated With Pulmonary Embolism But Not Deep Venous Thrombosis: Results From the Trauma Quality Improvement Program Database.

BACKGROUND: The mangled extremity (ME) is a limb with a multisystem injury (soft tissue, bone, nerves, or vessels). We hypothesized that trauma patients who present with mangled lower extremities (ME) experience a higher rate of venous thromboembolism when matched against trauma patients of similar injury burden without ME. MATERIALS AND METHODS: Data were abstracted from the Trauma Quality Improvement Program database from 2013 to 2016. Baseline comparisons were made between patients with and without ME. Propensity score matching with logistic regression modeling on the matched sample was performed controlling for patient gender, race, insurance status, age, injury severity score, Charlson comorbidity index, presence of significant other non-ME trauma, use of and time to prophylactic anticoagulation, placement of an inferior vena cava filter, and if immediate operative intervention was performed. RESULTS: A total of 1060 patients presented with an ME. Compared with other trauma patients, those with ME tended to be younger and male. They were more likely to receive prophylactic anticoagulation and an inferior vena cava filter. After propensity score matching, ME was statistically significantly associated with pulmonary embolism (PE) but not deep venous thrombosis (average treatment effect on the treated 1.7%, P = 0.04; and 1.4%, P = 0.22, respectively). These results were confirmed in a logistic regression on the matched sample (odds ratios 1.6, P = 0.11 for deep venous thrombosis, and odds ratio 3.2, P = 0.006 for PE). CONCLUSIONS: Patients with mangled lower extremities experience higher rates of PE. Based on these findings, institutions may consider evaluating their own VTE rates and chemoprophylaxis protocols in those with MEs.

Breast Reconstruction in an Underserved Population: A Retrospective Study.

BACKGROUND: Breast reconstruction can help restore the shape and appearance of breasts after surgery. Studies have shown that minority and uninsured patients are less likely to receive breast reconstruction after mastectomy. OBJECTIVE: We sought to determine if post-mastectomy reconstruction varied by patient ethnicity and insurance status in a medically underserved population. METHODS: This was a retrospective study of mastectomy patients seen at Bellevue Hospital Center, a safety-net hospital in New York City, between January 2010 and December 2015. The Chi square test was used to compare patient characteristics versus type of reconstruction chosen and likelihood of reconstruction. Logistic regression was used to examine likelihood of reconstruction, controlling for patient insurance status, race, age, stage at presentation, and contralateral prophylactic mastectomy. RESULTS: Of the 750 patients included in the database, 220 underwent mastectomy. Overall, 73.6% of our patient population received breast reconstruction. Patients with Medicare insurance were less likely to get reconstruction compared with patients with other types of insurance (37.5%, p = 0.04). Hispanic patients were most likely to receive reconstruction (89.1%), followed by Black patients (80%) and Asian patients (66.7%) [p = 0.03]. There were no significant associations between patient race or stage at presentation and type of reconstruction. In a multivariate logistic regression, advancing age was associated with a decreased likelihood of reconstruction (adjusted odds ratio 0.91, p < 0.001). CONCLUSIONS: In our underserved patient population, patients received breast reconstruction at rates higher than the national average. Institutional availability of patient navigators and preoperative counseling may contribute to more equal access to breast reconstruction.

The Use of Breast MRI for Patients With Preoperative Breast Cancer in an Underserved Population.

BACKGROUND: Use of MRI for preoperative evaluation of newly diagnosed breast cancer has become more common, despite questionable impact on outcomes. We sought to determine how often and in what manner preoperative breast MRI changed surgical management in an underserved patient population. MATERIALS AND METHODS: We examined the use of preoperative MRI at Bellevue Hospital Center (BHC), a public, tertiary hospital in lower Manhattan with a large underserved population. The BHC breast clinic database was used to identify patients who received preoperative MRI for breast cancer between January 2015 and December 2016. MRI was defined as changing surgical management in a positive manner if an MRI-detected abnormality had verification of malignancy in the final surgical specimen, confirming the MRI indication for wider excision or mastectomy, while MRI was defined to change surgical management in a negative manner if final pathology was discordant with MRI. Chi-square test was used to analyze characteristics of those who received MRI versus those who did not. RESULTS: A total of 208 patients underwent breast surgery at BHC, and 62 patients underwent MRI for preoperative planning purposes. There were significant differences between the MRI and no MRI group in terms of ethnicity (P = 0.05), age (P < 0.01), and type of surgery (P = 0.03). 50% of the biopsies performed as a result of MRI were benign. MRI changed surgical management in 35 % of patients, most commonly by converting lumpectomy to mastectomy. Of cases in which MRI changed surgical management, most were positive changes. However, 4 patients underwent surgery and 11 patients underwent biopsy for benign pathology as a result of MRI findings. CONCLUSIONS: MRI requires significant hospital and patient resource utilization. Especially in an underserved population, decision for MRI must be individualized, taking into account the risks and benefits of ordering this test.

Surgical treatment of young women with breast cancer: Public vs private hospitals.

Disparities in breast cancer treatment have been documented in young and underserved women. This study aimed to determine whether surgical disparities exist among young breast cancer patients by comparing cancer treatment at a public safety-net hospital (BH) and private cancer center (PCC) within a single institution. This was a retrospective study of young women (<45) diagnosed with invasive breast cancer (stage I-III) from 2011-2016. Patient information was abstracted from the breast cancer database at BH and PCC. Demographic variables, surgery type, method of presentation, and stage were analyzed using Pearson's chi-square tests and binary logistic regression. A total of 275 patients between ages 25-45 with invasive breast cancer (Stage I-III) were included in the study. There were 69 patients from BH and 206 patients from PCC. At PCC, the majority of patients were Caucasian (68%), followed by Asian (11%), Hispanic (10%), and African American (8.7%). At BH, patients were mostly Hispanic (47.8%), followed by Asian (27.5%), and African American (10.1%). At PCC, 82% had a college/graduate degree versus 18.6% of patients at BH (P < 0.001). All patients at PCC reported English as their primary language versus 30% of patients at BH (P < 0.001). Patients at PCC were more likely to present with lower stage cancer (P = 0.04), and less likely to present with a palpable mass (P = 0.04). Hospital type was not a predictor of receipt of mastectomy (P = 0.5), nor was race, primary language, or education level. Of patients who received a mastectomy, 87% at BH and 76% at PCC had immediate reconstruction. Surgical management of young women with breast cancer in a public hospital versus private hospital setting was equivalent, even after controlling for race, primary language, stage, and education level.

Age is a predictor for mortality after blunt splenic injury.

BACKGROUND: While the incidence of geriatric trauma continues to increase, the management of high-grade blunt splenic injury (BSI) in the elderly remains controversial. Among this population, data evaluating survival rates following non-operative and operative management are inconsistent. We analyzed mortality risk in geriatric patients with high-grade BSI based on operative vs. non-operative management. METHODS: A retrospective analysis of the National Trauma Database identified patients with isolated, high-grade (AIS ≥ 3) BSI from 2014 to 2015. Patients were stratified into three groups: non-elderly (<65 years), elderly (65-79 years), and advanced age (80 years and older). Each age group was stratified into three management groups: non-operative (including embolization), initial operative management (OR within 24 h), and failed non-operative management. Patient characteristics and outcomes were compared. Multivariable logistic regression estimated association with mortality. RESULTS: 5560 patients with isolated, high-grade BSI were identified. In the group that failed NOM, mortality was 2% in non-elderly patients, versus 22.2% in elderly patients and 50% in patients of advanced age (p < .01). In this group, patients over 80 years old spent an average of 6.5 days longer in the ICU vs. non-elderly patients (median 10.5 days, IQR [6.75, 19.5] vs. 4 days, IQR [3,6], p = 0.02). In patients with isolated, high grade BSI, age was independently associated with mortality (AOR 1.02; p < 0.01). Elderly patients who required surgery were over three times more likely to die (AOR 3.39; p < 0.01). Advanced age patients who required surgery were over eight times more likely to die (AOR 8.1; p < 0.01). CONCLUSIONS: For patients with BSI, age is independently associated with death in both operative and non-operative cases.

Hemobilia as a Complication of Transhepatic Percutaneous Biliary Drainage: a Rare Indication for Laparoscopic Common Bile Duct Exploration.

BACKGROUND: Hemobilia is the presence of blood in the biliary tree and is a frequent complication after percutaneous transhepatic biliary drainage (PTBD).1 Most of these episodes are self-limited; nevertheless, in less than 5% of cases, hemobilia is clinically significant, requiring an intervention (hepatic artery embolization, stenting, or percutaneous thrombin injection).2,3 Adequate treatment requires control of hemorrhage and restoration of bile flow. Surgery is the last resort and is indicated when the other modalities fail. METHODS: A 65-year-old man with multiple comorbidities was admitted with cholangitis. The patient underwent PTBD (Figure 1) but had persistent cholestasis. Thus, he underwent endoscopic cholangiopancreatography (ERCP), in which a plastic stent was misplaced within the common bile duct (CBD) and could not be removed (Figure 2). Afterwards, as the patient had persistently high bilirubin levels and the previously placed stent was malpositioned, the decision was made to proceed with laparoscopic cholecystectomy and CBD exploration. RESULTS: The operation was performed with choledocoscope guidance, and the CBD was closed over a T-tube. The operative time was 280 min. Postoperative course was uneventful; the T-tube was clamped 1 week after discharge. Four weeks postoperatively, the T-tube cholangiogram showed a patent extrahepatic biliary tree with no filling defects (Figure 3). The T-tube was then removed. CONCLUSIONS: Biliary obstruction secondary to hemobilia is a rare occurrence after PTBD. Surgical CBD exploration is required when conservative management and endoscopic treatment fail and can be done successfully through a minimally invasive approach.

Postinjury Complications: Retrospective Study of Causative Factors.

BACKGROUND: Injury care involves the complex interaction of patient, physician, and environment that impacts patient complications, level of harm, and failure to rescue (FTR). FTR represents the likelihood of a hospital to be unable to rescue patients from death after in-hospital complications. OBJECTIVE: This study aimed to hypothesize that error type and number of errors contribute to increased level of harm and FTR. METHODS: Patient information was abstracted from weekly trauma performance improvement (PI) records (from January 1, 2016, to July 19, 2017), where trauma surgeons determined the level of harm and identified the factors associated with complications. Level of harm was determined by definitions set forth by the Agency for Healthcare Research and Quality. Logistic regression was used to determine the impact of individual factors on FTR and level of harm, controlling for age, gender, Charlson score, injury severity score (ISS), error (in diagnosis, technique, or judgment), delay (in diagnosis or intervention), and need for surgery. RESULTS: A total of 2216 trauma patients presented during the study period. Of 2216 patients, 224 (224/2216, 10.10 %) had complications reported at PI meetings; of these, 31 patients (31/224, 13.8 %) had FTR. PI patients were more likely to be older (mean age 51.3 years, SE 1.58, vs 46.5 years, SE 0.51; P=.008) and have higher ISS (median 22 vs 8; P<.001), compared with patients without complications. Physician-attributable errors (odds ratio [OR] 2.82; P=.001), most commonly errors in technique, and nature of injury (OR 1.91; P=.01) were associated with higher levels of harm, whereas delays in diagnosis or intervention were not. Each additional factor involved increased level of harm (OR 2.09; P<.001) and nearly doubled likelihood of FTR (OR 1.95; P=.01). CONCLUSIONS: Physician-attributable errors in diagnosis, technique, or judgment are more strongly correlated with harm than delays in diagnosis and intervention. Increasing number of errors identified in patient care correlates with an increasing level of harm and FTR.

Patients with Psychiatric Disorders Require Greater Health-Care Resources after Injury.

The objective of this study was to assess whether patients with comorbid psychiatric conditions admitted after traumatic injury require greater health-care resource utilization. The trauma registry of a Level 1 trauma center was used to identify all adult trauma patients presenting from 2012 to 2015. Patients with psychiatric needs, identified as having either an ICD-9 code corresponding to a psychiatric disorder or requiring inpatient psychiatric consultation, were compared with controls, using propensity score matching. Patients with psychiatric disorders were more than three times more likely to present with penetrating injuries (odds ratio [OR] 3.5, P < 0.005). They had longer length of hospital stay (median 5 [IQR 2.5-11] vs. three days [IQR 1-7], P < 0.01), were approximately 70 per cent more likely to require ICU-level care (OR 1.68, P = 0.08), and were 80 per cent less likely to be discharged home (OR 0.18, P < 0.005). Trauma patients with psychiatric illness or need consume greater health-care resources.

Wiser with Age? Increased Per-Surgeon Elderly Patient Volume Is Associated with Lower Postinjury Complications.

We hypothesize that higher elderly patient volume per trauma surgeon is associated with fewer clinical complications. This is a retrospective cohort study which included elderly patients admitted to trauma surgery service within a five-year period, from 2009 to 2013, at two Level I trauma centers in Florida. Trauma surgeons were stratified into three groups depending on patient volume. Primary outcomes were postinjury complications and in-hospital mortality, and secondary outcomes were hospital length of stay (LOS), intensive care unit LOS, and ventilator days. A total of 2379 elderly patients were included in this study. Elderly patient volume per surgeon did not significantly differ based on years in practice after fellowship (P = 0.88). The higher volume group had lower incidence of complications (15% complication rate, P = 0.02), compared with the average and low-volume group (18.1 and 21%, respectively), and had significantly lower rates of acute respiratory failure (P = 0.04) and acute renal failure (P = 0.004). In-hospital mortality was not affected by volume. Hospital LOS was decreased in the higher volume group (mean LOS 7.4 days, P < 0.001). There appears to be a relationship between elderly patient volume and outcome, independent of surgeon years of experience.

Urban Bicyclist Trauma: Characterizing the Injuries, Consequent Surgeries, and Essential Sub-Specialties Providing Care.

In the United States in 2013, nearly 500,000 bicyclists were injured and required emergency department care. The objectives of this study were to describe the types of injuries which urban bicyclists sustain, to analyze the number and type of surgeries required, and to better delineate the services providing care. This is an observational study of injured bicyclists presenting to a Level I trauma center between February 2012 and August 2014. Most data were collected within 24 hours of injury and included demographics, narrative description of the incident, results of initial imaging studies, Injury Severity Score, admission status, length of stay, surgical procedure, and admitting and discharging service. A total of 706 injured bicyclists were included in the study, and 187 bicyclists (26.4%) required hospital admission. Of those admitted, 69 (36.8%) required surgery. There was no difference in gender between those who required surgery and those who did not (P = 0.781). Those who required surgery were older (mean age 39.1 vs 34.1, P = 0.003). Patients requiring surgery had higher Abbreviated Injury Scores for head (P ≤ 0.001), face (P ≤ 0.001), abdomen (P = 0.012), and extremity (P ≤ 0.001) and higher mean Injury Severity Scores (12.6 vs 3.7, P < 0.001). Sixty-nine patients required surgery and were brought to the operating room 82 times for 89 distinct procedures. Lower extremity injuries were the reason for 43 (48.3%) procedures, upper extremity injuries for 14 (15.7%), and facial injuries for 15 (16.9%). Orthopedic surgery performed 50 (56.2%) procedures, followed by plastic surgery (15 procedures; 16.8%). Trauma surgeons performed five (5.6%) procedures in four patients. The majority of admitted patients were admitted and discharged by the trauma service (70.1%, 56.7%, respectively) followed by the orthopedics service (13.9%, 19.8%, respectively). Injured bicyclists represent a unique subset of trauma patients. Orthopedic surgeons are most commonly involved in their operative management and rarely are the operative skills of a general traumatologist required. From a resource perspective, it is more efficient to direct the inpatient care of bicyclists with single-system trauma to the appropriate surgical subspecialty service soon after appropriate initial evaluation and treatment by the trauma service.