Publications by authors named "Ali Salim"

357 Publications

Impact of chronic illness on functional outcomes and quality of life among injured older adults.

Injury 2021 Mar 27. Epub 2021 Mar 27.

Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, MA USA; Harvard Medical School, Boston, MA, USA.

Introduction: Trauma care for injured older adults is complicated by pre-existing chronic illness. We examined the association between chronic illness and post-injury function, healthcare utilization and quality of life.

Methods: Trauma patients ≥65 years with an Injury Severity Score (ISS) ≥9 discharged from one of three level-1 trauma centers were interviewed 6-12 months post-discharge. Patients were asked about new functional limitations, injury-related emergency department (ED) visits or readmission, and health-related quality of life (HRQoL). Trauma registry data was used to determine presence of seven chronic illnesses. Adjusted regression models examined associations between increasing number of chronic illness (0, 1, ≥2) and outcomes.

Results: Of 1,379 patients, 46.5% had at least one chronic illness. In adjusted analysis, any chronic illness was associated with higher odds of new functional limitation (1 chronic illness, OR1.54, CI: 1.20-1.97; ≥2, OR1.69, CI: 1.16-2.48) and worse physical health-related QoL (1 chronic illness adj. mean diff= -4.0, CI: -5.6 to -2.5; ≥2 adj. mean diff.= -4.4, CI: -7.3 to -1.4, p<0.01). Mental health post-injury was consistent with population norms across all groups.

Conclusion: Presence of any chronic illness in older adults is associated with new functional limitations and worse physical HRQoL post-injury, but unchanged mental health. Focused interventions are needed to support long-term recovery.
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http://dx.doi.org/10.1016/j.injury.2021.03.052DOI Listing
March 2021

Systematic review of hospital-level metrics and interventions to increase deceased organ donation.

Transplant Rev (Orlando) 2021 Mar 6;35(3):100613. Epub 2021 Mar 6.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Transplantation, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America. Electronic address:

Background: Efforts to ameliorate the organ shortage have predominantly focused on improving processes and interventions at multiple levels in the organ donation process, but no comprehensive review of hospital-level features contributing to organ donation exists. We undertook a systematic review of the literature to better understand current knowledge and knowledge gaps about hospital-level metrics and interventions associated with successful organ donation.

Methods: We searched six electronic databases (PubMed, Embase, CINAHL, Web of Science, Health Business Elite, and Google scholar) and conference abstracts for articles on hospital-level features associated with the final outcome of organ donation (PROSPERO CRD42020187080). Editorials, letters to the editor, and reviews without original data were excluded. Our main outcomes were conversion rate, donation rate, number of organs recovered, number of donors, and authorization rate.

Results: Our search yielded 2177 studies, and after a thorough assessment, 72 articles were included in this systematic review. Studies were thematically categorized into 1) Hospital-level interventions associated with metrics of organ donation; these included patient- and family-centric measures (i.e. standardized interviews, collaborative requesting and decoupling, and dedicated in-house coordinators), and donor management goals that significantly increased conversion rates by up to 64%; 2) Hospital-level multi-stage programs/policies; which increased authorization rates between 30 and 50%; and 3) Hospital characteristics and qualities; being an academic center, trauma center and larger hospital correlated with higher authorization and conversion rates. Most studies had considerable risk of bias and were of low quality.

Conclusions: There is a lack of well-designed studies on hospital-level metrics and interventions associated with organ donation. The use of thoughtful, patient- and family-centric approaches to authorization generally is associated with more organ donors. Future work can build on what is known about the hospital role in organ donation to improve the entire organ donation process.
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http://dx.doi.org/10.1016/j.trre.2021.100613DOI Listing
March 2021

National estimates of intestinal ostomy creation and reversal for trauma.

J Trauma Acute Care Surg 2021 03;90(3):459-465

From the Center for Surgery and Public Health, Department of Surgery (Z.G.H., M.K.D., J.C.M., A.S., A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (Z.G.H.), Sinai Hospital of Baltimore, Baltimore, Maryland; Department of Surgery (S.S.S.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery (J.C.M.), St. Elizabeth's Medical Center, Boston, Massachusetts; and Medical College (A.H.H.), Aga Khan University, Karachi, Pakistan.

Background: Intestinal ostomy creation after trauma is selectively indicated for destructive colon and rectal injuries. However, the nationwide rates of creation of ostomies for trauma and their reversal are not known. The objective of this study was to ascertain national estimates of trauma ostomy creation and reversal.

Methods: Weighted analysis of Healthcare Cost and Utilization Project Nationwide Readmissions Database 2014 to 2015 was performed. Adult trauma patients (≥16 years) with a hollow viscus injury were included. Patients with preexisting ostomies and permanent ostomies and those who died within 48 hours of admission were excluded. Rates of ostomy creation and same admission ostomy reversal were calculated. Rates of postdischarge ostomy reversal were calculated using the Kaplan-Meier estimator. Multivariable Cox proportional hazards model was used to determine factors associated with postdischarge trauma ostomy reversal.

Results: A total of 22,542 patients sustained a hollow viscus injury resulting in the creation of 2,145 ostomies (9.6%). The rate of same-admission ostomy reversal was 0.7% (n = 16). At 1, 3, 6, and 9 months, the cumulative stoma reversal rates were 0%, 7.6%, 31.0%, and 43.1%, respectively. The mean ± SD time from ostomy creation to reversal was 123 ± 6.7 days for those undergoing reversal. Injury Severity Score greater than 9 was significantly associated with ostomy nonreversal after discharge (hazard ratio, 0.41; 95% confidence interval, 0.26-0.66). Age, sex, insurance status, penetrating injury, Charlson Comorbidity Index, and hospital teaching status were not significantly associated with ostomy reversal.

Conclusion: The nationwide rate of ostomy creation after trauma is nearly 10%. At 6 months postinjury, only one third of patients had undergone ostomy reversal. Future study is needed to understand patient and provider-level factors associated with trauma ostomy reversal.

Level Of Evidence: Epidemiology, level III.
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http://dx.doi.org/10.1097/TA.0000000000003022DOI Listing
March 2021

Wait expectations: The impact of delisting as an outcome from the kidney transplant waitlist.

Clin Transplant 2021 Feb 9:e14250. Epub 2021 Feb 9.

Center for Surgery and Public Health at Brigham and Women's Hospital, Boston, MA, USA.

Background: While kidney transplantation is optimal for the treatment of end-stage kidney disease, available organs do not meet demand. Little is known about the outcomes of patients who are delisted (removed from the waitlist) and unable to benefit from transplant. We describe patients who are delisted and their life expectancy after delisting.

Methods: Patients ≥ 18 years listed for deceased donor kidney transplant between 01/2003 and 12/2013 were identified in the Scientific Registry of Transplant Recipients and followed through 12/2018. A competing risk model was used to measure the association of demographic and clinical factors with waitlist outcomes of delisting, transplant, and death. Multivariate Cox modeling was used to evaluate factors associated with death after delisting.

Results: Of 324,582 patients listed, 18.0% were delisted, most common reasons were "too sick" or "other." After delisting, half (49.7%) had died by end of follow-up; time to death after removal was 5 years. Increasing age and public insurance were associated with increased risk of death.

Conclusions: Nearly one in five patients will be delisted from the kidney transplant waitlist. These patients live a surprisingly long time after removal. Much remains unknown about these patients, which could be improved through data collection. Delisting is an important patient outcome that warrants further exploration.
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http://dx.doi.org/10.1111/ctr.14250DOI Listing
February 2021

Sex differences in long-term outcomes after traumatic injury: A mediation analysis.

Am J Surg 2021 Jan 27. Epub 2021 Jan 27.

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: We sought to examine the association and potential mediators between sex and long-term trauma outcomes.

Methods: Moderately-to-severely injured patients admitted to 3 level-1 trauma centers were contacted between 6 and 12-months post-injury to assess for functional limitations, use of pain medications, and posttraumatic stress disorder (PTSD). Multivariable adjusted regression analyses were used to compare long-term outcomes by sex. Potential mediators of the relationship between sex and outcomes was explored using mediation analysis.

Results: 2607 patients were followed, of which 45% were female. Compared to male, female patients were more likely to have functional limitations (OR: 1.45; 95% CI: 1.31-1.60), take pain medications (OR: 1.17; 95% CI: 1.02-1.38), and screen positive for PTSD (OR: 1.60; 95% CI: 1.46-1.76) post-injury. Age, extremity injury, previous psychiatric illness, and pre-injury unemployment, partially mediated the effect of female sex on long-term outcomes.

Conclusions: There are significant sex differences in long-term trauma outcomes, which are partially driven by patient and injury-related factors.
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http://dx.doi.org/10.1016/j.amjsurg.2021.01.028DOI Listing
January 2021

Quantifying lives lost due to variability in emergency general surgery outcomes: Why we need a national emergency general surgery quality improvement program.

J Trauma Acute Care Surg 2021 04;90(4):685-693

From the Department of Surgery (Z.G.H., M.P.J., J.M.H., E.G., Z.C., A.S., A.H.H.), Brigham and Women's Hospital, Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (J.W.S.), University of Michigan, Ann Arbor, Michigan; Department of Emergency Medicine (E.G.), Brigham and Women's Hospital, Boston, Massachusetts; and The Dean's Office, Medical College (A.H.H.), Aga Khan University, Karachi, Pakistan.

Background: Nearly 4 million Americans present to hospitals with conditions requiring emergency general surgery (EGS) annually, facing significant morbidity and mortality. Unlike elective surgery and trauma, there is no dedicated national quality improvement program to improve EGS outcomes. Our objective was to estimate the number of excess deaths that could potentially be averted through EGS quality improvement in the United States.

Methods: Adults with the American Association for the Surgery of Trauma-defined EGS diagnoses were identified in the Nationwide Emergency Department Sample 2006 to 2014. Hierarchical logistic regression was performed to benchmark treating hospitals into reliability adjusted mortality quintiles. Weighted generalized linear modeling was used to calculate the relative risk of mortality at each hospital quintile, relative to best-performing quintile. We then calculated the number of excess deaths at each hospital quintile versus the best-performing quintile using techniques previously used to quantify potentially preventable trauma deaths.

Results: Twenty-six million EGS patients were admitted, and 6.5 million (25%) underwent an operation. In-hospital mortality varied from 0.3% to 4.1% across the treating hospitals. Relative to the best-performing hospital quintile, an estimated 158,177 (153,509-162,736) excess EGS deaths occurred at lower-performing hospital quintiles. Overall, 47% of excess deaths occurred at the worst-performing hospitals, while 27% of all excess deaths occurred among the operative cohort.

Conclusion: Nearly 200,000 excess EGS deaths occur across the United States each decade. A national initiative to enable structures and processes of care associated with optimal EGS outcomes is urgently needed to achieve "Zero Preventable Deaths after Emergency General Surgery."

Level Of Evidence: Care management, level IV.
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http://dx.doi.org/10.1097/TA.0000000000003074DOI Listing
April 2021

Traumatic Brain Injury: Does Admission Service Matter?

J Surg Res 2021 03 10;259:211-216. Epub 2020 Dec 10.

Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington. Electronic address:

Background: Traumatic brain injury (TBI) is common, and significant institutional variation exists with regards to structure and processes of care. Affected patients may be admitted to one of several different services, and this may drive differential care and outcomes. We sought to evaluate differential care and outcomes for patients with isolated mild-to-moderate traumatic brain injury based on admission service.

Materials And Methods: This is a single-institution retrospective study of all adult (≥18 y old) patients admitted with isolated TBI (AIS ≤1 in all other body regions) over a 3-year period (6/2015-6/2018). Patients who underwent neurosurgical intervention (craniectomy/craniotomy) and those with a head AIS ≥4 were excluded. Patients were assigned to one of three groups based upon admission service: Trauma Surgery, Neurology/Medicine or Neurosurgery. Outcomes evaluated included in-hospital mortality and markers of differential care. We performed multivariate analyses adjusting for patient demographics and clinical characteristics.

Results: A total of 401 isolated mild-to-moderate TBI patients were identified. Overall mortality was 1.7%. Adjusted multivariate logistic regression analysis demonstrated no difference in mortality. Patients admitted to Neurosurgery underwent more repeat head CTs and were more likely to receive antiseizure medication in the absence of seizure activity, and those admitted to Neurology/Medicine were less likely to receive venous thromboembolism chemoprophylaxis compared to those admitted to Trauma Surgery.

Conclusions: We identify several important metrics of variation in care received by patients with an isolated mild-to-moderate TBI based upon admission service. These findings deserve further study, and this study may lay the foundation for future efforts at protocolizing care in an evidence-based fashion for this patient cohort.
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http://dx.doi.org/10.1016/j.jss.2020.09.033DOI Listing
March 2021

Long-term outcomes of psychoactive drug use in trauma patients: A multicenter patient-reported outcomes study.

J Trauma Acute Care Surg 2021 02;90(2):319-324

From the Division of Trauma, Emergency Surgery, and Surgical Critical Care (M.E.M., K.B., G.V., H.M.A.K.), Massachusetts General Hospital; Department of Surgery (J.P.H.-E., A.S.), Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School; Center for Surgery and Public Health (J.P.H.-E., C.O., A.N.H., A.S.), Brigham and Women's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health; Department of Psychiatry (N.C.L.-C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burn and Critical Care Surgery (D.N.), Harborview Medical Center, University of Washington, Seattle, Washington; Division of Trauma, Acute Care Surgery and Surgical Critical Care (S.E.S.), Boston University School of Medicine, Boston, Massachusetts.

Introduction: Psychoactive drug use (PDU) is reported in up to 40% of trauma patients and is associated with a higher rate of in-hospital complications. However, little is known about its long-term impact on trauma patients. We aimed to assess the long-term functional, mental, and psychosocial outcomes of PDU in trauma patients 6 to 12 months after injury.

Methods: Trauma patients with moderate to severe injuries (Injury Severity Score, >9) who had a toxicology screen upon admission to one of three level 1 trauma centers were contacted by phone 6 to 12 months postinjury. Psychoactive drug use was defined as the presence of a psychoactive, nonprescribed substance on toxicology screen including amphetamine, barbiturate, benzodiazepine, cannabinoid, methamphetamine, methadone, opioid, oxycodone, methylenedioxymethamphetamine (ecstasy), phencyclidine, tricyclic antidepressant, and cocaine. The interviews systematically evaluated functional limitations, social functioning, chronic pain, and mental health (posttraumatic stress disorder, depression, anxiety). Patients with a score of ≤47 on the Short-Form Health Survey version 2.0 social functioning subdomain were considered to have social dysfunction. Multivariable regression models were built to determine the independent association between PDU and long-term outcomes.

Results: Of the 1,699 eligible patients, 571 (34%) were included in the analysis, and 173 (30.3%) screened positive for PDU on admission. Patients with PDU were younger (median age [interquartile range], 43 [28-55] years vs. 66 [46-78] years, p < 0.001), had more penetrating injuries (8.7% vs. 4.3%, p = 0.036), and were less likely to have received a college education (41.3% vs. 54.5%, p = 0.004). After adjusting for patients' characteristics including the presence of a baseline psychiatric comorbidity, patients with PDU on admission were more likely to suffer from daily chronic pain, mental health disorders, and social dysfunction 6 to 12 months after injury. There was no difference in the functional limitations between patients with and without PDU.

Conclusion: On the long term, PDU in trauma patients is strongly and independently associated with worse mental health, more chronic pain, and severe impairment in social functioning. A trauma hospitalization presents an opportunity to identify patients at risk and to mitigate the long-term impact of PDU on recovery.

Level Of Evidence: Prognostic/epidemiologic, level III.
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http://dx.doi.org/10.1097/TA.0000000000003032DOI Listing
February 2021

Association of Frailty With Morbidity and Mortality in Emergency General Surgery by Procedural Risk Level.

JAMA Surg 2021 Jan;156(1):68-74

Division of Trauma, Burn, and Surgical Critical Care, Surgery Department, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: In this aging society, older patients are more commonly undergoing emergency general surgery (EGS). Although frailty has been associated with worse outcomes in this population, EGS encompasses a heterogeneous mix of procedures.

Objective: To determine if the association of frailty with morbidity and mortality in EGS patients varies based on the level of procedural risk.

Design, Setting, And Participants: This cross-sectional study analyzed Medicare inpatient claims file (January 2007-December 2015) and included all inpatients who underwent 1 of 7 previously described EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Analysis took place from September 2019 to January 2020.

Exposures: The primary exposure of interest was risk procedural level. EGS procedures were stratified as high risk (excision of small intestine, excision of large intestine, peptic ulcer repair, lysis of peritoneal adhesions, and laparotomy) and low risk (appendectomy and cholecystectomy).

Main Outcomes And Measures: The primary outcome was overall 30-day mortality after discharge. Frailty was assessed using a claims-based frailty index. Multivariate logistic regression analysis was used and was stratified by risk level.

Results: A total of 882 929 EGS patients were included in this study (mean [SD] age, 77.9 [7.5] years; 483 637 [54%] were female). Overall mortality was 4.5% (n = 40 304). The frailty index classified 12.6% (n = 111 513) of patients as frail, and mortality within this group was 9.9% (n = 11 307). High-risk procedures represented 53% (n = 468 098) of the caseload, and mortality was 6.8% (n = 31 979). For low-risk procedures, mortality was 2% (n = 8325). Frailty was significantly associated with mortality (odds ratio, 1.64; 95% CI, 1.60-1.68). After stratified analysis, this association remained significant for high-risk (odds ratio, 1.53; 95% CI, 1.49-1.58) and low-risk (odds ratio, 2.05; 95% CI, 1.94-2.17) procedures.

Conclusions And Relevance: Frailty was significantly associated with mortality in patients undergoing EGS, with an even greater association in low-risk procedures. Preoperative frailty assessment is imperative even in low-risk procedures.
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http://dx.doi.org/10.1001/jamasurg.2020.5397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689563PMC
January 2021

A National Assessment of Trauma Systems Using the American College of Surgeons NBATS Tool: Geographic Distribution of Trauma Center Need.

Ann Surg 2020 Oct 15. Epub 2020 Oct 15.

Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.

Objective: To compare the Needs Based Assessment of Trauma Systems (NBATS) tool estimates of trauma center need to the existing trauma infrastructure using observed national trauma volume.

Summary Background Data: Robust trauma systems have improved outcomes for severely injured patients. The NBATS tool was created by the American College of Surgeons (ACS) to align trauma resource allocation with regional needs.

Methods: Data from the Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases, the Trauma Information Exchange Program, and US Census was used to calculate an NBATS score for each trauma service area (TSA) as defined by the Pittsburgh Atlas. This score was used to estimate the number of trauma centers allocated to each TSA and compared to the number of existing trauma centers.

Results: NBATS predicts the need for 117 additional trauma centers across the United States in order to provide adequate access to trauma care nationwide. At least one additional trauma center is needed in 49% of trauma service areas.

Conclusions: Application of the NBATS tool nationally shows the need for additional trauma infrastructure across a large segment of the United States. We identified some limitations of the NBATS tool, including preferential weighting based on current infrastructure. The NBATS tool provides a good framework to begin the national discussion around investing in the expansion of trauma systems nationally, however in many instances lacks the granularity to drive change at the local level.
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http://dx.doi.org/10.1097/SLA.0000000000004555DOI Listing
October 2020

Inflammatory Responses in Oro-Maxillofacial Region Expanded Using Anisotropic Hydrogel Tissue Expander.

Materials (Basel) 2020 Oct 6;13(19). Epub 2020 Oct 6.

Dean's Office, Faculty of Dentistry, University of Malaya, Kuala Lumpur 50603, Malaysia.

Objective: Reconstruction of oral and facial defects often necessitate replacement of missing soft tissue. The purpose of tissue expanders is to grow healthy supplementary tissue under a controlled force. This study investigates the inflammatory responses associated with the force generated from the use of anisotropic hydrogel tissue expanders.

Methods: Sprague Dawley rats (n = 7, body weight = 300 g ± 50 g) were grouped randomly into two groups-control (n = 3) and expanded (n = 4). Anisotropic hydrogel tissue expanders were inserted into the frontal maxillofacial region of the rats in the expanded group. The rats were sacrificed, and skin samples were harvested, fixed in formalin, and embedded in paraffin wax for histological investigation. Hematoxylin and eosin staining was performed to detect histological changes between the two groups and to investigate the inflammatory response in the expanded samples. Three inflammatory markers, namely interleukin (IL)-1α, IL-6, and tumor necrosis factor-α (TNF-α), were analyzed by immunohistochemistry.

Result: IL-1-α expression was only observed in the expanded tissue samples compared to the controls. In contrast, there was no significant difference in IL-6, and TNF-α production. Histological analysis showed the absence of inflammatory response in expanded tissues, and a negative non-significant correlation (Spearman's correlation coefficient) between IL-1-α immune-positive cells and the inflammatory cells (r = -0.500). In conclusion, tissues that are expanded and stabilized using an anisotropic self-inflating hydrogel tissue expander might be useful for tissue replacement and engraftment as the expanded tissue does not show any sign of inflammatory responses. Detection of IL-1-α in the expanded tissues warrants further investigation for its involvement without any visible inflammatory response.
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http://dx.doi.org/10.3390/ma13194436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579169PMC
October 2020

A Multistate Study of Race and Ethnic Disparities in Access to Trauma Care.

J Surg Res 2021 01 8;257:486-492. Epub 2020 Sep 8.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts. Electronic address:

Background: There are well-documented disparities in outcomes for injured Black and Hispanic patients in the United States. However, patient level characteristics cannot fully explain the differences in outcomes and system-level factors, including the trauma center designation of the hospital to which a patient presents, may contribute to their worse outcomes. We aim to determine if Black and Hispanic patients are more likely to be undertriaged, compared with white patients.

Methods: This is a retrospective, cross-sectional, population-based study that uses data from the 2014 Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases. We included data from all states with available State Inpatient Databases data that included both race and hospital characteristics needed for analysis (n = 18). Logistic regression was used to identify predictors of severely injured (Injury Severity Score ≥16) patients being brought to a trauma center.

Results: We identified 70,970 severely injured trauma patients with complete data. Non-Hispanic White represented 74.1% of the study population, 9.8% were non-Hispanic Black, and 9.7% were Hispanic. After adjustment for other demographic and injury characteristics, Non-Hispanic Black and Hispanic patients were more likely to be undertriaged, compared with white patients (odds ratio, 1.20; 95% confidence interval, 1.12-1.29 and odds ratio, 1.39; 95% confidence interval, 1.29-1.48, respectively). Male sex and older age were associated with higher odds of undertriage, whereas urban residence, high injury severity, and penetrating injury were associated with lower odds of undertriage.

Conclusions: Severely injured Black and Hispanic trauma patients are more likely to be undertriaged than otherwise similar white patients. The factors that contribute to racial and ethnic disparities in receiving trauma center care need to be identified and addressed to provide equitable trauma care.
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http://dx.doi.org/10.1016/j.jss.2020.08.031DOI Listing
January 2021

COVID-19 patient bridged to recovery with veno-venous extracorporeal membrane oxygenation.

J Card Surg 2020 Oct 15;35(10):2869-2871. Epub 2020 Jul 15.

Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: In severe cases, the coronavirus disease 2019 (COVID-19) viral pathogen produces hypoxic respiratory failure unable to be adequately supported by mechanical ventilation. The role of extracorporeal membrane oxygenation (ECMO) remains unknown, with the few publications to date lacking detailed patient information or management algorithms all while reporting excessive mortality.

Methods: Case report from a prospectively maintained institutional ECMO database for COVID-19.

Results: We describe veno-venous (VV) ECMO in a COVID-19-positive woman with hypoxic respiratory dysfunction failing mechanical ventilation support while prone and receiving inhaled pulmonary vasodilator therapy. After 9 days of complex management secondary to her hyperdynamic circulation, ECMO support was successfully weaned to supine mechanical ventilation and the patient was ultimately discharged from the hospital.

Conclusions: With proper patient selection and careful attention to hemodynamic management, ECMO remains a reasonable treatment option for patients with COVID-19.
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http://dx.doi.org/10.1111/jocs.14829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405208PMC
October 2020

Defining a Research Agenda for Layperson Prehospital Hemorrhage Control: A Consensus Statement.

JAMA Netw Open 2020 07 1;3(7):e209393. Epub 2020 Jul 1.

Forum on Medical and Public Health Preparedness for Catastrophic Events, National Academies of Science, Washington, DC.

Importance: Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector.

Objective: To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons.

Evidence Review: The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda.

Findings: Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy.

Conclusions And Relevance: The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.9393DOI Listing
July 2020

Reduced chronic pain: Another benefit of recovery at an inpatient rehabilitation facility over a skilled nursing facility?

Am J Surg 2021 01 19;221(1):216-221. Epub 2020 May 19.

Department of Surgery, Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: We sought to compare outcomes 6-12 months post-injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF).

Methods: Trauma patients admitted to 3 Level-I trauma centers were interviewed to evaluate the presence of daily pain requiring medication, functional outcomes, and physical and mental health-related quality-of-life at 6-12 months post-injury. Inverse-probability-of-treatment-weighting (IPTW)-adjusted analyses were performed to compare outcomes between patients who were discharged to IRF vs SNF.

Results: A total of 519 patients were included: 389 discharged to IRFs and 130 to SNFs. In adjusted analyses, IRF was associated with a significant reduction in the likelihood of chronic pain after injury (28.3% vs. 44.7%; OR:0.49; 95% CI, 0.26-0.91; P = .02). However, there were no significant differences in functional outcome or SF-12 composite scores between groups.

Conclusion: Our findings suggest that injured patients discharged to an IRF as compared to a SNF had less chronic pain and analgesic use.
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http://dx.doi.org/10.1016/j.amjsurg.2020.05.019DOI Listing
January 2021

Patient-reported Outcomes at 6 to 12 Months Among Survivors of Firearm Injury in the United States.

Ann Surg 2020 Jan 16. Epub 2020 Jan 16.

Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA.

Objective: Assess outcomes in survivors of firearm injuries after 6 to 12 months and compared them with a similarly injured trauma population.

Background: For every individual in the United States who died of a firearm injury in 2017, three survived, living with the burden of their injury. Current firearm research largely focuses on mortality and short-term health outcomes, while neglecting the long-term consequences.

Methods: We contacted adult patients with a moderate-to-severe injury from a firearm or motor vehicle crash (MVC) treated at 3 level I trauma centers in Boston between 2015 and 2018. Patients were contacted 6 to 12 months postinjury to measure: presence of daily pain; screening for post-traumatic stress disorder (PTSD); new functional limitations; return to work; and physical and mental health-related quality of life. We matched each firearm injury patient to MVC patients using Coarsened Exact Matching. Adjusted Generalized Linear Models were used to compare matched patients.

Results: Of 177 eligible firearm injury survivors, 100 were successfully contacted and 63 completed the study. Among them, 67.7% reported daily pain, 53.2% screened positive for PTSD, 38.7% reported a new functional limitation in an activity of daily living, and 59.1% have not returned to work. Compared with population norms, overall physical and mental health-related quality of life was significantly reduced among firearm injury survivors. Compared with matched MVC survivors (n = 255), firearm injury survivors were significantly more likely to have daily pain [adjusted odds ratio (OR) 2.30, 95% confidence interval (CI) 1.08-4.87], to screen positive for PTSD (adjusted OR 3.06, 95% CI 1.42-6.58), and had significantly worse physical and mental health-related quality of life.

Conclusions: This study highlights the need for targeted long-term follow-up care, physical rehabilitation, mental health screening, and interventions for survivors of firearm violence.
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http://dx.doi.org/10.1097/SLA.0000000000003797DOI Listing
January 2020

Mental Health Burden After Injury: It's About More than Just Posttraumatic Stress Disorder.

Ann Surg 2020 Jun 4. Epub 2020 Jun 4.

Department of Surgery, Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School. Boston, MA.

Objective: Assess the prevalence of anxiety, depression, and posttraumatic stress disorder (PTSD) after injury and their association with long-term functional outcomes.

Background: Mental health disorders (MHD) after injury have been associated with worse long-term outcomes. However, prior studies almost exclusively focused on PTSD.

Methods: Trauma patients with an injury severity score ≥9 treated at 3 Level-I trauma centers were contacted 6-12 months post-injury to screen for anxiety (generalized anxiety disorder-7), depression (patient health questionnaire-8), PTSD (8Q-PCL-5), pain, and functional outcomes (trauma quality of life instrument, and short-form health survey)). Associations between mental and physical outcomes were established using adjusted multivariable logistic regression models.

Results: Of the 531 patients followed, 108 (20%) screened positive for any MHD: of those who screened positive for PTSD (7.9%, N = 42), all had co-morbid depression and/or anxiety. In contrast, 66 patients (12.4%) screened negative for PTSD but positive for depression and/or anxiety. Compared to patients with no MHD, patients who screened positive for PTSD were more likely to have chronic pain {odds ratio (OR): 8.79 [95% confidence interval (CI): 3.21, 24.08]}, functional limitations [OR: 7.99 (95% CI: 3.50, 18.25)] and reduced physical health [β: -9.3 (95% CI: -13.2, -5.3)]. Similarly, patients who screened positive for depression/anxiety (without PTSD) were more likely to have chronic pain [OR: 5.06 (95% CI: 2.49, 10.46)], functional limitations [OR: 2.20 (95% CI: 1.12, 4.32)] and reduced physical health [β: -5.1 (95% CI: -8.2, -2.0)] compared to those with no MHD.

Conclusions: The mental health burden after injury is significant and not limited to PTSD. Distinguishing among MHD and identifying symptom-clusters that overlap among these diagnoses, may help stratify risk of poor outcomes, and provide opportunities for more focused screening and treatment interventions.
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http://dx.doi.org/10.1097/SLA.0000000000003780DOI Listing
June 2020

Customised structural, optical and antibacterial characteristics of cinnamon nanoclusters produced inside organic solvent using 532 nm Q-switched Nd:YAG-pulse laser ablation.

Opt Laser Technol 2020 Oct 21;130:106331. Epub 2020 May 21.

Biosciences Department, Faculty of Science, UniversitiTeknologi Malaysia, 81310 Johor Bahru, Johor, Malaysia.

Biomedical values of organic natural cinnamon that are buried in their bulk counterpart can be exposed and customised via nanosizing. Based on this factor, a new type of spherical cinnamon nanoclusters (Cin-NCs) were synthesised using eco-friendly nanosecond pulse laser ablation in liquid (PLAL) approach. As-grown nontoxic Cin-NCs suspended in the citric acid of pH 4.5 (acted as organic solvent) were characterised thoroughly to evaluate their structural, optical and bactericidal properties. The effects of various laser fluences (LF) at the fixed wavelength (532 nm) on the physiochemical properties of these Cin-NCs were determined. The FTIR spectra of the Cin-NCs displayed the symmetric-asymmetric stretching of the functional groups attached to the heterocyclic/cinnamaldehyde compounds. The HR-TEM image of the optimum sample revealed the nucleation of the crystalline spherical Cin-NCs with a mean diameter of approximately 10 ± 0.3 nm and lattice fringe spacing around 0.14 nm. In addition, the inhibition zone diameter (IZD) and optical density (OD) of the proposed Cin-NCs were measured to assess their antibacterial potency against the (IZD ≈ 24 mm) and (IZD ≈ 25 mm) bacterial strains. The strong UV absorption (in the range of 269 and 310 nm) shown by these NCs was established to be useful for the antibacterial drug development and food treatment.
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http://dx.doi.org/10.1016/j.optlastec.2020.106331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239794PMC
October 2020

ACR Appropriateness Criteria® Major Blunt Trauma.

J Am Coll Radiol 2020 May;17(5S):S160-S174

Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.

This review assesses the appropriateness of various imaging studies for adult major blunt trauma or polytrauma in the acute setting. Trauma is the leading cause of mortality for people in the United States <45 years of age, and the fourth leading cause of death overall. Imaging, in particular CT, plays a critical role in the management of these patients, and a number of indications are discussed in this publication, including patients who are hemodynamically stable or unstable; patients with additional injuries to the face, extremities, chest, bowel, or urinary system; and pregnant patients. Excluded from consideration in this review are penetrating traumatic injuries, burns, and injuries to pediatric patients. Patients with suspected injury to the head and spine are also discussed more specifically in other appropriateness criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.024DOI Listing
May 2020

The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty.

J Sex Med 2020 05 20;17(5):1033-1040. Epub 2020 Mar 20.

Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUMC, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUMC, Amsterdam, the Netherlands.

Background: Penile inversion vaginoplasty is a commonly performed genital gender-affirming procedure in transgender women. The creation of an adequate functional neovaginal depth in cases of too little usable penile skin is a challenge. The bilateral pedicled epilated scrotal flap (BPES-flap) can be used as an easy adjunctive technique and may serve as a tool in the surgical armamentarium of the gender surgeon.

Aim: To describe the use, dissection, design subtypes, and surgical outcomes of the BPES-flap in vaginoplasty.

Methods: Perioperative considerations and different flap design subtypes were described to illustrate the possible uses of the BPES-flap in vaginoplasty. A retrospective chart study was performed on the use of this flap in 3 centers (blinded for review purposes).

Outcomes: The main outcome measures are description of surgical technique, flap design possibilities, and postoperative complications.

Results: A total of 42 transgender women were included (median age: 28 years (range 18-66), mean body mass index: 24.5 ± 3.5). The mean penile length and width preoperatively were 9 ± 3.1 and 2.9 ± 0.2 cm, respectively. With a mean follow up of 13 ± 10 months, total flap necrosis occurred in one case (2.4%). Partial flap necrosis occurred also in one. Neovaginal reconstruction was successful in all patients with a mean vaginal depth of 13.5 ± 1.3 cm and width of 3.3 ± 1.3 cm. Partial prolapse of the neovaginal top occurred in 3 patients (7%).

Clinical Implications: The BPES-flap is a useful addition to the arsenal of surgeons performing feminizing genital reconstructive surgery.

Strengths & Limitations: Strenghts comprise (1) the description of the surgical technique with clear images, (2) completeness of data, and (3) that data are from a multicenter study. A weakness is the retrospective nature with limited follow-up time.

Conclusion: The BPES-flap is a vascularized scrotal flap that can be raised on the bilateral inferior superficial perineal arteries. It may be used for neovaginal depth creation during vaginoplasty and may be quicker to perform than full-thickness skin grafting. Nijhuis THJ, Özer M, van der Sluis WB, et al. The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty. J Sex Med 2020;17:1033-1040.
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http://dx.doi.org/10.1016/j.jsxm.2020.02.024DOI Listing
May 2020

Care Discontinuity in Emergency General Surgery: Does Hospital Quality Matter?

J Am Coll Surg 2020 06 27;230(6):863-871. Epub 2020 Feb 27.

Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.

Background: Changes in care providers and hospitals after emergency general surgery (EGS) (care discontinuity) are associated with increased morbidity and mortality. The cause of these worse outcomes is unknown. Our goal was to determine if hospital quality is associated with mortality after readmissions independent of continuity in care.

Study Design: This was a retrospective analysis of Medicare inpatient claims (2007 to 2015). All inpatients older than 65 years of age who underwent 1 of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally, were included. Care discontinuity was defined as readmission within 30 days to a nonindex hospital. Hospital quality was determined by hospital-level, risk-adjusted mortality rates by EGS procedure and categorized into high quality (HQ) and low quality (LQ). The primary outcome was overall mortality. Multivariate logistic regression analysis was used to determine the association of discontinuity and mortality.

Results: There were 882,929 EGS patients, 87,232 of whom were readmitted within 30 days of discharge. Care discontinuity was independently associated with mortality (odds ratio [OR] 1.23; 95% CI 1.17 to 1.29). When readmitted patients were stratified by quality of index and readmitting hospital, mortality was associated with the quality of both the index hospital and the readmitting hospital. The highest mortality rate was observed in patients with index admission at low-quality hospitals and readmission to a different low-quality hospital.

Conclusions: Both care discontinuity and hospital quality are independently associated with mortality in EGS patients. These data support maintaining continuity of care, even at low performing hospitals.
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http://dx.doi.org/10.1016/j.jamcollsurg.2020.02.025DOI Listing
June 2020

Urethrographic Evaluation of Anatomic Findings and Complications after Perineal Masculinization and Phalloplasty in Transgender Patients.

Radiographics 2020 Mar-Apr;40(2):393-402. Epub 2020 Jan 31.

From the Departments of Radiology (A.D.B., K.M., H.L.), Gynecology (M.Y.M.), and Surgery (A.M.S.), Kaiser Permanente San Francisco Medical Center, 2425 Geary Blvd, San Francisco, CA 94115; Department of Obstetrics and Gynecology, Kaiser Permanente San Diego Medical Center, San Diego, Calif (J.T.K.); and Department of Urology, Kaiser Permanente San Jose Medical Center, San Jose, Calif (D.R.).

Transgender patients seeking gender-affirming surgery are a growing population with unique health care needs. The radiologist must understand the challenges these patients face to facilitate a positive patient-physician interaction during the series of postoperative fluoroscopic evaluations. The authors present a standard two-stage surgical approach and common postoperative fluoroscopic findings after perineal masculinization and phalloplasty procedures. Perineal masculinization including urethral lengthening is performed first, followed by skin-flap-based phalloplasty. Patients undergo voiding cystourethrography (VCUG) after intravesical administration of contrast media by way of an indwelling suprapubic catheter after each stage. Retrograde urethrography plays a complementary role to supplement the limitations of VCUG after the second stage. The article reviews the expected postoperative anatomy and explains standardized terminology developed at the authors' institution. Imaging features of common and rare complications are discussed, including contained leak, stenosis, occlusion, and fistula. The successful postoperative imaging study in a transmasculine patient relies on open communication among the interdisciplinary team of specialized surgeons, radiologists, and medical providers, as well as special modifications to existing imaging techniques. RSNA, 2020.
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http://dx.doi.org/10.1148/rg.2020190143DOI Listing
April 2021

The National Burden of Orthopedic Injury: Cross-Sectional Estimates for Trauma System Planning and Optimization.

J Surg Res 2020 05 25;249:197-204. Epub 2020 Jan 25.

Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Management of orthopedic injuries is a critical component of comprehensive trauma care. As patterns of injury incidence and recovery change in the face of emerging injury prevention efforts and technologies and an aging US population, assessment of the burden of orthopedic injury is essential to optimize trauma system planning. We sought to estimate the incidence of orthopedic injury requiring emergency orthopedic surgery in the United States.

Methods: Using nationally representative samples from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, we estimated the incidence of orthopedic injury, polytrauma with orthopedic injury, and emergency operative orthopedic procedures performed for the management of traumatic injury. We used multivariable logistic regression to identify patient, injury, and hospital characteristics associated with odds of emergency orthopedic surgery.

Results: A total of 7,214,915 patients were diagnosed with orthopedic injury in 2013-2014, resulting in 1,167,656 emergency orthopedic surgical procedures. Fall-related injuries accounted for 51% of health care encounters and 61% of emergency orthopedic surgical procedures. Odds of emergency orthopedic surgery were 2.04 times greater for patients with polytrauma, compared with isolated orthopedic injury (P < 0.001).

Conclusions: The total burden or orthopedic injury in the United States is substantial, and there is considerable heterogeneity in demand for care and practice patterns in the orthopedic trauma community. Population-based trauma system planning and tailored care delivery models would likely optimize initial treatment, recovery, and health outcomes for orthopedic trauma patients.
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http://dx.doi.org/10.1016/j.jss.2019.12.023DOI Listing
May 2020

Detecting Invasive Fungal Disease in Surgical Patients: Utility of the (13)- β-d-Glucan Assay.

Surg Infect (Larchmt) 2020 Jun 2;21(5):461-464. Epub 2020 Jan 2.

Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.

The specificity and sensitivity of the (13)-β-d-glucan (BDG) assay in surgical patients needs further investigation. We hypothesized that the BDG assay would have lower sensitivity/specificity compared with that of medical patients. We reviewed patients who had undergone laparotomy, gastrectomy, hepatectomy, or colectomy and had a BDG assay post-operatively. A total of 71 patients met study criteria. There were 29 (40.8%) who had proven/probable invasive fungal infection. Sensitivity for BDG level ≥80 diagnosed within one week of the assay draw was 77.3% (95% confidence interval [CI], 54.6-92.2%), and specificity was 44.9% (95% CI, 30.7-59.8). The positive predictive value was 38.6% (95% CI, 31.0-46.9%), and negative predictive value was 82.5% (95% CI, 65.7-91.0%). A BDG assay result of 149 pg/mL had a classification rate of 63.4%. Therefore, a BDG assay result ≥150 pg/mL has a sensitivity of 78.6% and a specificity of 41.4%. A BDG assay can be useful for ruling out invasive fungemia in post-operative patients.
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http://dx.doi.org/10.1089/sur.2019.247DOI Listing
June 2020

Risk Prediction Accuracy Differs for Transferred and Nontransferred Emergency General Surgery Cases in the ACS-NSQIP.

J Surg Res 2020 03 22;247:364-371. Epub 2019 Nov 22.

Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.

Background: Risk prediction accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator has been shown to differ between emergency and elective surgery. Benchmarking methods of clinical performance require accurate risk estimation, and current methods rarely account for admission source; therefore, our goal was to assess whether the ACS-NSQIP predicts mortality comparably between transferred and nontransferred emergency general surgery (EGS) cases.

Materials And Methods: This is a retrospective study using the ACS-NSQIP database from 2005 to 2014including all inpatients who underwent one of seven previously described EGS procedures. The admission source was classified as directly admitted versus transferred from an outside emergency room or an acute care facility. We compared the accuracy of ACS-NSQIP-predicted mortality probabilities using the observed-to-expected (O:E) ratio and Brier score. A subgroup analysis was performed to compare accuracy of high-risk and low-risk procedures.

Results: A total of 206,103 EGS admissions were identified, of which 6.97% were transfers. Overall mortality was 3.26% for the entire cohort and 10.24% within the transfer group. The O:E ratios generated by ACS-NSQIP models differed between transferred patients (O:E = 1.0, 95% confidence interval = 0.97-1.02) and nontransferred patients (O:E = 1.12, 95% confidence interval = 1.09-1.14). The Brier score for transferred patients was greater than that for nontransferred patients (0.063 versus 0.018, respectively) showing higher accuracy for nontransferred patients.

Conclusions: The ACS-NSQIP risk estimates used for benchmarking differ between transferred and nontransferred EGS cases. Analyses of the Brier score by the ACS-NSQIP risk calculator demonstrated inferior prediction for transferred patients. This increased burden on accepting institutions will have an impact on quality metrics and should be considered for benchmarking of clinical performance.
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http://dx.doi.org/10.1016/j.jss.2019.10.007DOI Listing
March 2020

National Study of Triage and Access to Trauma Centers for Older Adults.

Ann Emerg Med 2020 02 13;75(2):125-135. Epub 2019 Nov 13.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.

Study Objective: To identify predictors of undertriage among older injured Medicare beneficiaries, identify any regions in which undertriage is more likely to occur, and examine additional factors associated with undertriage at a national level.

Methods: Using 2009 to 2014 Medicare claims data, we identified older adults (≥65 years) receiving a diagnosis of traumatic injury, and linked claims with trauma center designation records from the American Trauma Society. Undertriage was defined as nontrauma centers treatment with an Injury Severity Score greater than or equal to 16, consistent with the American College of Surgeons Committee on Trauma benchmark. We used multivariable logistic regression to estimate odds of undertriage by census region, adjusting for sex, race, age, Injury Severity Score, trauma center proximity, and mode of transportation.

Results: Forty-six percent of severely injured patients (n=125,731) were treated at a nontrauma center. Compared with that for patients in the Midwest, adjusted odds of undertriage were 100% higher for patients in Southern states (odds ratio [OR] 2.00; 95% confidence interval [CI] 2.00 to 2.04) and 78% higher in Western states (OR 1.78; 95% CI 1.73 to 1.82). Compared with that for patients aged 65 to 69 years, odds of undertriage gradually increased in all age groups, reaching 57% for patients older than 80 years (OR 1.57; 95% CI 1.52 to 1.61). Distance to a trauma center was associated with increasing odds of undertriage, with 37% higher odds (OR 1.37; 95% CI 1.15 to 1.40) for older adults living more than 30 miles from a trauma center compared with patients living within 15 miles.

Conclusion: Nearly half of older adult trauma patients are undertriaged; it increases with age and distance to care and is most common in Southern and Western states. Improvements to field triage and trauma center access for older patients are urgently needed.
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February 2020

Development and validation of a revised trauma-specific quality of life instrument.

J Trauma Acute Care Surg 2020 04;88(4):501-507

From the Center for Surgery and Public Health, Brigham and Women's Hospital (J.P.H.-E., S.S.A.R., A.T., A.H.H.), Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (T.D.-C.), Medical College of Wisconsin, Milwaukee, Milwaukee; Division of Trauma, Critical Care and Acute Care Surgery (K.B.), Department of Surgery, Oregon Health and Science University, Portland, Oregon; Division of Trauma, Burn and Surgical Critical Care (D.N., A.S.), Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Trauma and Critical Care Surgery (G.K.), Department of Surgery, Duke University School of Medicine, Durham, North Carolina; and Division of Trauma, Emergency Surgery, and Surgical Critical Care (G.V.), Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Background: The National Academies of Science has called for routine collection of long-term outcomes after injury. One of the main barriers for this is the lack of practical trauma-specific tools to collect such outcomes. The only trauma-specific long-term outcomes measure that applies a biopsychosocial view of patient care, the Trauma Quality-of-Life (T-QoL), has not been adopted because of its length, lack of composite scores, and unknown validity. Our objective was to develop a shorter version of the T-QoL measure that is reliable, valid, specific, and generalizable to all trauma populations.

Methods: We used two random samples selected from a prospective registry developed to follow long-term outcomes of adult trauma survivors (Injury Severity Score ≥9) admitted to three level I trauma centers. First, we validated the original T-QoL instrument using the 12-Item Short-Form Health Survey (SF-12) version 2.0 and Breslau post-traumatic stress disorder screening (B-PTSD) tools. Second, we conducted a confirmatory factor analysis to reduce the length of the original T-QoL instrument, and using a different sample, we scored and performed internal consistency and validity assessments of the revised T-QoL (RT-QoL) components.

Results: All components of the original T-QoL were significantly correlated negatively with the B-PTSD and positively with the SF-12 mental and physical composite scores. After confirmatory factor analysis, a three-component structure using 18 items (six items/component) most appropriately represented the data. Each component in the revised instrument demonstrated a high level of internal consistency (Cronbach's α ≥0.8) and correlated negatively with the B-PTSD and positively with the SF-12, demonstrating concurrent validity. In addition, each of the RT-QoL components was able to distinguish between individuals based on their work status, with those who have returned to work reporting better health.

Conclusion: This more practical RT-QoL measure greatly increases the ability to evaluate long-term outcomes in trauma more efficiently and meaningfully, without sacrificing the validity and psychometric properties of the original instrument.

Level Of Evidence: Prognostic and epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002505DOI Listing
April 2020

Resilience and long-term outcomes after trauma: An opportunity for early intervention?

J Trauma Acute Care Surg 2019 10;87(4):782-789

From the Division of Trauma, Burn and Surgical Critical Care, Department of Surgery (D.N., J.H., R.A., S.N., A.S., A.H.), Center for Surgery and Public Health (J.P.H-E., S.S.A.R., J.H., A.H.), Brigham and Women's Hospital, Harvard Medical School; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery (G.V.), Massachusetts General Hospital, Harvard Medical School; Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery (G.K.), Boston University School of Medicine, Boston, Massachusetts; Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery (K.J.B.), Oregon Health and Science University. Portland, Oregon; and Department of Psychiatry (N.L-C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Resilience, or the ability to cope with difficulties, influences an individual's response to life events including unexpected injury. We sought to assess the relationship between patient self-reported resilience traits and functional and psychosocial outcomes 6 months after traumatic injury.

Methods: Adult trauma patients 18 years to 64 years of age with moderate to severe injuries (Injury Severity Score, ≥9) admitted to one of three Level I trauma centers between 2015 and 2017 were contacted by phone at 6 months postinjury and asked to complete a validated Trauma Quality of Life (T-QoL) survey and PTSD screen. Patients were classified into "low" and "high" resilience categories. Long-term outcomes were compared between groups. Adjusted logistic regression models were built to determine the association between resilience and each of the long-term outcomes.

Results: A total of 305 patients completed the 6-month interview. Two hundred four (67%) of the 305 patients were classified as having low resilience. Mean age was 42 ± 14 years, 65% were male, 91% suffering a blunt injury, and average Injury Severity Score was 15.4 ± 7.9. Patients in the low-resilience group had significantly higher odds of functional limitations in activities of daily living (odds ratio [OR], 4.81; 95% confidence interval [CI], 2.48-9.34). In addition, patients in the lower resilience group were less likely to have returned to work/school (OR, 3.25; 95% CI, 1.71-6.19), more likely to report chronic pain (OR, 2.57; 95% CI, 1.54-4.30) and more likely to screen positive for PTSD (OR, 2.96; 95% CI, 1.58-5.54).

Conclusion: Patients with low resilience demonstrated worse functional and psychosocial outcomes 6 months after injury. These data suggest that screening for resilience and developing and deploying early interventions to improve resilience-associated traits as soon as possible after injury may hold promise for improving important long-term functional outcomes.

Level Of Evidence: Prognostic, level II.
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http://dx.doi.org/10.1097/TA.0000000000002442DOI Listing
October 2019

The role of the American Society of anesthesiologists physical status classification in predicting trauma mortality and outcomes.

Am J Surg 2019 12 24;218(6):1143-1151. Epub 2019 Sep 24.

Department of Surgery, Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine, 333 City Blvd. West, Suite 1600, Orange, CA, 92868, USA.

Background: Trauma prediction scores such as Revised Trauma Score (RTS) and Trauma and Injury Severity Score (TRISS)) are used to predict mortality, but do not include comorbidities. We analyzed the American Society of Anesthesiologists physical status (ASA PS) for predicting mortality in trauma patients undergoing surgery.

Methods: This multicenter, retrospective study compared the mortality predictive ability of ASA PS, RTS, Injury Severity Score (ISS), and TRISS using a complete case analysis with mixed effects logistic regression. Associations with mortality and AROC were calculated for each measure alone and tested for differences using chi-square.

Results: Of 3,042 patients, 230 (8%) died. The AROC for mortality for TRISS was 0.938 (95%CI 0.921, 0.954), RTS 0.845 (95%CI 0.815, 0.875), and ASA PS 0.886 (95%CI 0.864, 0.908). ASA PS + TRISS did not improve mortality predictive ability (p = 0.18).

Conclusions: ASA PS was a good predictor of mortality in trauma patients, although combined with TRISS it did not improve predictive ability.
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http://dx.doi.org/10.1016/j.amjsurg.2019.09.019DOI Listing
December 2019

Natural Language Processing Accurately Measures Adherence to Best Practice Guidelines for Palliative Care in Trauma.

J Pain Symptom Manage 2020 02 25;59(2):225-232.e2. Epub 2019 Sep 25.

Department of Surgery, University of California, San Diego, La Jolla, California, USA; Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Context: The Trauma Quality Improvement Program Best Practice Guidelines recommend palliative care (PC) concurrent with restorative treatment for patients with life-threatening injuries. Measuring PC delivery is challenging: administrative data are nonspecific, and manual review is time intensive.

Objectives: To identify PC delivery to patients with life-threatening trauma and compare the performance of natural language processing (NLP), a form of computer-assisted data abstraction, to administrative coding and gold standard manual review.

Methods: Patients 18 years and older admitted with life-threatening trauma were identified from two Level I trauma centers (July 2016-June 2017). Four PC process measures were examined during the trauma admission: code status clarification, goals-of-care discussion, PC consult, and hospice assessment. The performance of NLP and administrative coding were compared with manual review. Multivariable regression was used to determine patient and admission factors associated with PC delivery.

Results: There were 76,791 notes associated with 2093 admissions. NLP identified PC delivery in 33% of admissions compared with 8% using administrative coding. Using NLP, code status clarification was most commonly documented (27%), followed by goals-of-care discussion (18%), PC consult (4%), and hospice assessment (4%). Compared with manual review, NLP performed more than 50 times faster and had a sensitivity of 93%, a specificity of 96%, and an accuracy of 95%. Administrative coding had a sensitivity of 21%, a specificity of 92%, and an accuracy of 68%. Factors associated with PC delivery included older age, increased comorbidities, and longer intensive care unit stay.

Conclusion: NLP performs with similar accuracy with manual review but with improved efficiency. NLP has the potential to accurately identify PC delivery and benchmark performance of best practice guidelines.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.09.017DOI Listing
February 2020