Publications by authors named "Jeffry Nahmias"

127 Publications

General Surgery Residency Match: Time for More than a Virtual Change.

J Surg Educ 2021 Jul 30. Epub 2021 Jul 30.

University of California, Irvine, Department of Surgery, Orange, California. Electronic address:

The 2020-2021 General Surgery Residency Match presents unique challenges in the setting of the COVID-19 pandemic and highlights pre-existing concerns. In order to move toward an equitable and manageable surgical residency application process for both programs and applicants, systemic change is warranted.
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http://dx.doi.org/10.1016/j.jsurg.2021.06.003DOI Listing
July 2021

The DEPARTS Score: A Novel Tool for Predicting Discharge Disposition in Geriatric Trauma Patients.

Am Surg 2021 Jul 9:31348211029843. Epub 2021 Jul 9.

Department of Surgery, 8788University of California Irvine, Orange, CA, USA.

Background: Geriatric trauma patients (GTPs) represent a high-risk population for needing post-acute care, such as skilled nursing facilities (SNFs) and long-term acute care hospitals (LTACs), due to a combination of traumatic injuries and baseline functional health. As there is currently no well-established tool for predicting these needs, we aimed to create a scoring tool that predicts disposition to SNFs/LTACs in GTPs.

Methods: The adult 2017 Trauma Quality Improvement Program database was divided at random into two equal sized sets (derivation and validation sets) of GTPs >65 years old. First, multiple logistic regression models were created to determine risk factors for discharge to a SNF/LTAC in admitted GTPs. Second, the weighted average and relative impact of each independent predictor was used to derive a DEPARTS (ischarge of lderly atients fter ecent rauma to NF/LTAC) score. We then validated the score using the area under the receiver-operating curve (AROC).

Results: Of 66 479 patients in the derivation set, 36 944 (55.6%) were discharged to a SNF/LTAC. Number of comorbidities, fall mechanism, spinal cord injury, long bone fracture, and major surgery were each independent predictors for discharge to SNF/LTAC, and a DEPARTS score was derived with scores ranging from 0 to 19. The AROC for this was .74. In the validation set, 66 477 patients also had a SNF/LTAC discharge rate of 55.7%, and the AROC was .74.

Discussion: The DEPARTS score is a good predictor of SNF/LTAC discharge for GTPs. Future prospective studies are warranted to validate its accuracy and clinical utility in preventing delays in discharge.
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http://dx.doi.org/10.1177/00031348211029843DOI Listing
July 2021

Vices-paradox in trauma: Positive alcohol and drug screens associated with decreased mortality.

Drug Alcohol Depend 2021 Jun 25;226:108866. Epub 2021 Jun 25.

University of California, Irvine, Department of Surgery, Division of Trauma, Burns, Surgical Critical Care and Acute Care Surgery, Orange, CA, USA.

Background: Improved survival in trauma patients with acute alcohol intoxication has been previously reported. The effect of illegal and controlled substances on mortality is less clear. We hypothesized that alcohol, illegal and controlled substances are each independently associated with lower odds of mortality in adult trauma patients.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for patients screening positive for alcohol, illegal or controlled substances on admission. A multivariate logistic regression analysis was used to determine odds of mortality. A similar analysis was used after stratification by injury severity scale (ISS).

Results: From 1,299,705 adult patients, 660,135 were screened for substance use. Of these patients, 497,872 were male, 227,995 (34.5 %) screened positive for alcohol, 155,437 (23.5 %) for illegal substances and 90,259 (13.7 %) for controlled substances. Mortality rate was 6.2 % with alcohol, 5.1 % with illegal substances, and 5.7 % with controlled substances compared to 8.0 % with no substance use (p < 0.001). After controlling for covariates, all groups had lower odds of mortality: alcohol (OR = 0.88, CI = 0.84-0.92, p < 0.001), illegal substances (OR = 0.83, CI = 0.77-0.90, p < 0.001), controlled substances (OR = 0.72, CI = 0.67-0.79, p < 0.001). When stratified by ISS, alcohol and illegal substances continued to be associated with decreased mortality until ISS 50. Controlled substances were associated with decreased mortality when ISS > 16.

Conclusion: Patients positive for alcohol, illegal or controlled substances have 12 %, 17 %, and 28 % decreased odds of mortality, respectively. This paradoxical association should be confirmed with future clinical studies and merits basic science research to identify biochemical or physiological components conferring a protective effect on survival in trauma patients.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108866DOI Listing
June 2021

Improved outcomes over time for adult COVID-19 patients with acute respiratory distress syndrome or acute respiratory failure.

PLoS One 2021 25;16(6):e0253767. Epub 2021 Jun 25.

Department of Surgery, University of California Irvine, Orange, California, United States of America.

Background: COVID-19's pulmonary manifestations are broad, ranging from pneumonia with no supplemental oxygen requirements to acute respiratory distress syndrome (ARDS) with acute respiratory failure (ARF). In response, new oxygenation strategies and therapeutics have been developed, but their large-scale effects on outcomes in severe COVID-19 patients remain unknown. Therefore, we aimed to examine the trends in mortality, mechanical ventilation, and cost over the first six months of the pandemic for adult COVID-19 patients in the US who developed ARDS or ARF.

Methods And Findings: The Vizient Clinical Data Base, a national database comprised of administrative, clinical, and financial data from academic medical centers, was queried for patients ≥ 18-years-old with COVID-19 and either ARDS or ARF admitted between 3/2020-8/2020. Demographics, mechanical ventilation, length of stay, total cost, mortality, and discharge status were collected. Mann-Kendall tests were used to assess for significant monotonic trends in total cost, mechanical ventilation, and mortality over time. Chi-square tests were used to compare mortality rates between March-May and June-August. 110,223 adult patients with COVID-19 ARDS or ARF were identified. Mean length of stay was 12.1±13.3 days and mean total cost was $35,991±32,496. Mechanical ventilation rates were 34.1% and in-hospital mortality was 22.5%. Mean cost trended downward over time (p = 0.02) from $55,275 (March) to $18,211 (August). Mechanical ventilation rates trended down (p<0.01) from 53.8% (March) to 20.3% (August). Overall mortality rates also decreased (p<0.01) from 28.4% (March) to 13.7% (August). Mortality rates in mechanically ventilated patients were similar over time (p = 0.45), but mortality in patients not requiring mechanical ventilation decreased from March-May compared to June-July (13.5% vs 4.6%, p<0.01).

Conclusions: This study describes the outcomes of a large cohort with COVID-19 ARDS or ARF and the subsequent decrease in cost, mechanical ventilation, and mortality over the first 6 months of the pandemic in the US.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253767PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232521PMC
July 2021

Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial).

J Trauma Acute Care Surg 2021 Jul;91(1):100-107

From the Division of Acute Care Surgery (K. McArthur), Loma Linda University School of Medicine, Loma Linda, California; Division of Acute Care Surgery (C.K., E.K., X.L.-O., M.C.-Y., S.B., D.T., K. Mukherjee), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma, Burns, Critical Care, and Acute Care Surgery (L.S., C.K., A.G., J. Nahmias), UC Irvine Medical Center, Irvine, California; Division of Trauma and Critical Care (A.B., A.G.), LAC+USC Medical Center, Los Angeles, California; Grant Medical Center Trauma Services (A.L., M.K.), Ohio Health Grant Medical Center, Columbus, Ohio; Division of Trauma/Surgical Critical Care (M.N.F., N.G.), Rutgers-New Jersey Medical School, Newark, New Jersey; Division of Trauma (S.T., E.L.), Cedars-Sinai Medical Center, Los Angeles, California; Division of Trauma and Surgical Critical Care (S.R.L., O.D.G.), Vanderbilt University Medical Center, Nashville, Tennessey; Division of Trauma/Acute Care Surgery/Critical Care (J.M.B., C.D.), West Virginia University, Morgantown, West Virginia; Division of Trauma (S.M.W., K.L.), Cooper University Health System, Camden, New Jersey; Section of Acute Care Surgery (N.T.D., J. Nunez), University of Utah Medical Center, Salt Lake City, Utah; Division of Trauma and Critical Care Surgery (S.M., J.P.), Northwestern Memorial Hospital, Chicago, Illinois; Division of Trauma, Emergency Surgery and Surgical Critical Care (L.N., H. Kaafarani), Massachusetts General Hospital, Boston, Massachusetts; Trauma Center (H. Kemmer, M.J.L.), Research Medical Center-Kansas City Hospital, Kansas City, Missouri; Mount Sinai Hospital-Chicago (A.D., G.C.), Chicago, Illinois; and Trauma and Acute Care Center (Z.N.), Morristown Medical Center, Morristown, New Jersey.

Background: Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population.

Methods: We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head.

Results: Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001).

Conclusion: Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury.

Level Of Evidence: Therapeutic study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000003210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8331055PMC
July 2021

Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study.

J Trauma Acute Care Surg 2021 Jul;91(1):24-33

From the Department of Surgery at Zuckerberg San Francisco General Hospital, University of California San Francisco (Z.A.M., Z.J.H., R.A.C., B.N.-G., L.Z.K., E.E.R., J.J.P., B.R., M.K.A., A.T.F.), San Francisco, California; Department of Epidemiology and Biostatistics, University of California San Francisco (E.C.M), San Francisco, California; Department of Laboratory Medicine, University of California, San Francisco (J.H.E., A.N., J.M.), San Francisco, California; Department of Surgery, University of California Irvine (W.D., J.N.), Irvine, Orange, California; Department of Surgery, Ohio Health Grant Medical Center (A.K.L., M.C.S.), Columbus, Ohio; Department of Surgery, University of Kentucky (S.S.D., J.K.R.), Lexington, Kentucky; Department of Surgery, Miami Valley Hospital (H.L., Y.W., C.H.), Dayton, Ohio; Department of Surgery, R Adams Cowley Shock Trauma Center (A.M.C., R.A.K., P.T.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery, Loma Linda Medical Center (L.P., K.M., X.L.-O.), Loma Linda, California; Department of Surgery, University of Kansas Medical Center (K.T., C.A.G.), Kansas City, Kansas; Department of Surgery, Crozer-Chester Medical Center (S.S.S., A.R.), Upland, Pennsylvania; Department of Surgery, WakeMed Health and Hospitals (A.M., P.U., A.S., B.P., K.T.), Raleigh, North Carolina; Department of Surgery, University of New Mexico School of Medicine (K.M., S.A.M.), Albuquerque, New Mexico; Department of Surgery, Wellspan York Hospital (J.G.), York, Pennsylvania; Department of Surgery, Ascension Via Christi Hospitals St. Francis (J.K., J.H., K.L.), Wichita, Kansas; Department of Surgery, Maine Medical Center (J.B.O., D.C.C.), Portland, Maine; Department of Surgery, South Shore Hospital/Brigham and Women's Hospital (S.A.S., J.C.K.), Boston, Massachusetts; Department of Surgery, Penn State Hershey Medical Center (J.G., J.P.H.), Hershey, Pennsylvania; Department of Surgery, Northwestern University Feinberg School of Medicine (A.Z.B., J.A.P.), Chicago, Illinois; Department of Surgery, University of California (R.A.C.), UC Davis, Sacramento, California; Department of Surgery, Ryder Trauma Center (K.A.J., G.R.), University of Miami Miller School of Medicine, Miami, Florida; and Washington University School of Medicine St. Louis (J.K.), Missouri.

Background: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era.

Methods: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality.

Results: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%).

Conclusion: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication.

Level Of Evidence: Prognostic, level III.
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http://dx.doi.org/10.1097/TA.0000000000003121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243874PMC
July 2021

Increased Mortality in Underinsured Penetrating Trauma Patients.

Am Surg 2021 Jun 15:31348211024974. Epub 2021 Jun 15.

Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA.

Introduction: It remains unclear whether an increased mortality risk in uninsured patients exists across Injury Severity Score (ISS) classifications. We hypothesized that penetrating trauma self-pay patients would have a similarly increased mortality risk across all ISS categories.

Methods: The National Trauma Data Bank (2013-2015) was queried for patients presenting with penetrating firearm, explosive, or stab wound injuries. 115 651 patients were identified and a stratified multivariable logistic regression model was used.

Results: In the >15 ISS group, self-pay patients had a lower median total hospital Length of Stay (LOS) (3 vs 8, < .001), lower median Intensive Care Unit LOS (1 vs 3, < .001), and lower median ventilator days (0 vs 1, < .001). Self-pay patients had an increased risk for mortality compared to patients with private insurance in both the ≤15 ISS group (OR 2.68, < .001) and >15 ISS group (OR 1.56, < .001).

Conclusion: Uninsured patients have an increased mortality risk in both low and high ISS groups. A higher mortality risk among uninsured patients in the high ISS group can be explained by decreased resource availability and lower ICU days and ventilator time. However, more studies are needed to determine why there is an even greater mortality risk among uninsured patients with mild ISS.
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http://dx.doi.org/10.1177/00031348211024974DOI Listing
June 2021

Prehospital Variables Alone Can Predict Mortality After Blunt Trauma: A Novel Scoring Tool.

Am Surg 2021 Jun 15:31348211024192. Epub 2021 Jun 15.

Department of Surgery, University of California, Irvine, Orange, CA, USA.

Background: We sought to develop a novel Prehospital Injury Mortality Score (PIMS) to predict blunt trauma mortality using only prehospital variables.

Study Design: The 2017 Trauma Quality Improvement Program database was queried and divided into two equal sized sets at random (derivation and validation sets). Multiple logistic regression models were created to determine the risk of mortality using age, sex, mechanism, and trauma activation criterion. The PIMS was derived using the weighted average of each independent predictor. The discriminative power of the scoring tool was assessed by calculating the area under the receiver operating characteristics (AUROC) curve. The PIMS ability to predict mortality was then assessed by using the validation cohort. The score was compared to the Revised Trauma Score (RTS) using the AUROC curve, including a subgroup of patients with normal vital signs.

Results: The derivation and validation groups each consisted of 163 694 patients. Seven independent predictors of mortality were identified, and the PIMS was derived with scores ranging from 0 to 20. The mortality rate increased from 1.4% to 43.9% and then 100% at scores of 1, 10, and 19, respectively. The model had very good discrimination with an AUROC of .79 in both the derivation and validation groups. When compared to the RTS, the AUROC were similar (.79 vs. .78). On subgroup analysis of patients with normal prehospital vital signs, the PIMS was superior to the RTS (.73 vs. .56).

Conclusion: The PIMS is a novel scoring tool to predict mortality in blunt trauma patients using prehospital variables. It had improved discriminatory power in blunt trauma patients with normal vital signs compared to the RTS.
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http://dx.doi.org/10.1177/00031348211024192DOI Listing
June 2021

Drug and alcohol positivity of traumatically injured patients related to COVID-19 stay-at-home orders.

Am J Drug Alcohol Abuse 2021 Jun 4:1-7. Epub 2021 Jun 4.

Department of Surgery, University of California, Irvine, CA, USA.

: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, < .001 and = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, < .001 and = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, < .001 and < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, = .003 and < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups ( > .05).: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.
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http://dx.doi.org/10.1080/00952990.2021.1904967DOI Listing
June 2021

COVID-19 in trauma: a propensity-matched analysis of COVID and non-COVID trauma patients.

Eur J Trauma Emerg Surg 2021 May 25. Epub 2021 May 25.

Department of Surgery, University of California, Irvine (UCI), 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.

Purpose: There is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients.

Methods: A retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019-6/30/2019 and 1/1/2020-6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups.

Results: A total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p < 0.001) and intensive care unit LOS (1.40 vs 0.80 days, p = 0.008), compared to non-COVID patients.

Conclusion: This multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients.
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http://dx.doi.org/10.1007/s00068-021-01699-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8143988PMC
May 2021

No Difference in Morbidity or Mortality Between Octogenarians and Other Geriatric Burn Trauma Patients.

Am Surg 2021 Apr 16:31348211011122. Epub 2021 Apr 16.

Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 8788University of California Irvine, Orange, CA, USA.

Background: Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate than younger adults. With the population of the US aging, the number of elderly burn and trauma patients is expected to increase. A past study using the National Burn Repository revealed a linear increase in mortality for those >65 years old. We hypothesized that octogenarians with burn and trauma injuries would have a higher rate of in-hospital complications and mortality, than patients aged 65-79 years old.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for burn trauma patients. To detect mortality risk a multivariable logistic regression model was used.

Results: From 282 patients, there were 73 (25.9%) octogenarians and 209 (74.1%) aged 65-79 years old. The two cohorts had similar median injury severity scores (16 vs. 15 in octogenarians, = .81), total body surface area burned ( = .30), and comorbidities apart from an increased smoking (12.9% vs. 4.1%, = .04) and decreased hypertension (52.2% vs. 65.8%, = .04) in the younger cohort. Octogenarians had similar complications, including acute respiratory distress syndrome, pulmonary embolism, deep vein thrombosis ( > .05), and mortality (15.1% vs. 10.5%, = .30), compared to the younger cohort. Octogenarians were not associated with an increased mortality risk (odds ratio 1.51, confidence interval 0.24-9.56, = .67).

Discussion: Among burn trauma patients ≥65 years, age should not be a sole predictor for mortality risk. Continued research is necessary in order to determine more accurate approaches to prognosticate mortality in geriatric burn trauma patients, such as the validation and refinement of a burn-trauma-related frailty index.
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http://dx.doi.org/10.1177/00031348211011122DOI Listing
April 2021

The coronavirus disease 2019 (COVID-19) stay-at-home order's unequal effects on trauma volume by insurance status in Southern California.

Surgery 2021 Mar 5. Epub 2021 Mar 5.

University of California, Irvine (UCI), Department of Surgery, Orange, CA.

Background: The rapid spread of coronavirus disease 2019 in the United States led to a variety of mandates intended to decrease population movement and "flatten the curve." However, there is evidence some are not able to stay-at-home due to certain disadvantages, thus remaining exposed to both coronavirus disease 2019 and trauma. We therefore sought to identify any unequal effects of the California stay-at-home orders between races and insurance statuses in a multicenter study utilizing trauma volume data.

Methods: A posthoc multicenter retrospective analysis of trauma patients presenting to 11 centers in Southern California between the dates of January 1, 2020, and June 30, 2020, and January 1, 2019, and June 30, 2019, was performed. The number of trauma patients of each race/insurance status was tabulated per day. We then calculated the changes in trauma volume related to stay-at-home orders for each race/insurance status and compared the magnitude of these changes using statistical resampling.

Results: Compared to baseline, there was a 40.1% drop in total trauma volume, which occurred 20 days after stay-at-home orders. During stay-at-home orders, the average daily trauma volume of patients with Medicaid increased by 13.7 ± 5.3%, whereas the volume of those with Medicare, private insurance, and no insurance decreased. The average daily trauma volume decreased for White, Black, Asian, and Latino patients with the volume of Black and Latino patients dropping to a similar degree compared to White patients.

Conclusion: This retrospective multicenter study demonstrated that patients with Medicaid had a paradoxical increase in trauma volume during stay-at-home orders, suggesting that the most impoverished groups remain disproportionately exposed to trauma during a pandemic, further exacerbating existing health disparities.
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http://dx.doi.org/10.1016/j.surg.2021.02.060DOI Listing
March 2021

Analysis of COVID-19 Patients With Acute Respiratory Distress Syndrome Managed With Extracorporeal Membrane Oxygenation at US Academic Centers.

Ann Surg 2021 07;274(1):40-44

Department of Surgery, University of California, Irvine Medical Center, Orange, CA.

Objective: This study analyzed the outcomes of COVID-19 patients with ARDS who were managed with extracorporeal membrane oxygenation (ECMO) across 155 US academic centers.

Summary Background Data: ECMO has been utilized in COVID-19 patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia. Early case series with the use of ECMO in these patients reported high mortality exceeding 90%.

Methods: Using ICD-10 codes, data of patients with COVID-19 with ARDS, managed with ECMO between April and September 2020, were analyzed using the Vizient clinical database. Outcomes measured included in-hospital mortality, hospital and ICU length of stay, and direct cost. For comparative purposes, the outcome of a subset of COVID-19 patients aged between 18 and 64 years and managed with versus without ECMO were examined.

Results: 1,182 patients with COVID-19 and ARDS received ECMO. In-hospital mortality was 45.9%, mean length of stay was 36.8 ± 24.9 days, and mean ICU stay was 29.1 ± 17.3 days. In-hospital mortality according to age group was 25.2% for 1 to 30 years; 42.2% for 31 to 50 years; 53.2% for 51 to 64 years; and 73.7% for ≥65 years. A subset analysis of COVID-19 patients, aged 18 to 64 years with ARDS requiring mechanical ventilation and managed with (n = 1113) vs without (n = 16,343) ECMO, showed relatively high in-hospital mortality for both groups (44.6% with ECMO vs 37.9% without ECMO).

Conclusions: In this large US study of patients with COVID-19 and ARDS managed with ECMO, the in-hospital mortality is high but much lower than initial reports. Future research is needed to evaluate which patients with COVID-19 and ARDS would benefit from ECMO.
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http://dx.doi.org/10.1097/SLA.0000000000004870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189255PMC
July 2021

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries.

J Trauma Acute Care Surg 2021 05;90(5):776-786

From the Scripps Memorial Hospital La Jolla (WLB, FZZ, MC, KBS), La Jolla, CA; Maine Medical Center (BM), Portland, ME; Memorial Hermann Hospital (MM), Houston, TX; University of Oklahoma (JL), Oklahoma City, OK; Ryder Trauma Center (SB), Miami, FL; University of California-San Diego (JW), San Diego, CA; San Francisco General Hospital (RC, LK), San Francisco, CA; University of Calgary (CCGB), Calgary, Alberta, Canada; University of California-Irvine (JN), Irvine, CA; North Memorial Health Hospital (MW), Robbinsdale, MN; University of California-Davis (GJJ), Sacramento, CA; Grady Memorial Hospital (SRT), Atlanta, GA; Hadassah- Hebrew University Medical Center (MB), Jerusalem, Israel; Grant Medical Center (CS), Columbus, OH; Ernest E. Moore Shock Trauma Center at Denver Health (EEM), Denver, CO.

Background: Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time.

Methods: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate.

Results: Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs.

Conclusion: Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice.

Level Of Evidence: Retrospective diagnostic/therapeutic study, level III.
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May 2021

Injury and Mortality Profiles in Level II and III Trauma Centers.

Am Surg 2021 Mar 27:3134820966290. Epub 2021 Mar 27.

Department of Surgery, University of California, Irvine, CA, USA.

Background: While the benefit of admission to trauma centers compared to non-trauma centers is well-documented and differences in outcomes between Level-I and Level-II trauma centers are well-studied, data on the differences in outcomes between Level-II trauma centers (L2TCs) and Level-III trauma centers (L3TCs) are scarce.

Objectives: We sought to compare mortality risk between patients admitted to L2TCs and L3TCs, hypothesizing no difference in mortality risk for patients treated at L3TCs compared to L2TCs.

Methods: A retrospective analysis of the 2016 Trauma Quality Improvement Program (TQIP) database was performed. Patients aged 18+ years were divided into 2 groups, those treated at American College of Surgeons (ACS) verified L2TCs and L3TCs.

Results: From 74,486 patients included in this study, 74,187 (99.6%) were treated at L2TCs and 299 (.4%) at L3TCs. Both groups had similar median injury severity scores (ISSs) (10 vs 10, < .001); however, L2TCs had a higher mean ISS (14.6 vs 11.9). There was a higher mortality rate for L2TC patients (6.0% vs 1.7%, = .002) but no difference in associated risk of mortality between the 2 groups (OR .46, CI .14-1.50, = .199) after adjusting predictors of mortality. L2TC patients had a longer median length of stay (5.0 vs 3.5 days, < .001). There was no difference in other outcomes including myocardial infarction (MI) and cerebrovascular accident (CVA) ( > .05).

Discussion: Patients treated at L2TCs had a longer LOS compared to L3TCs. However, after controlling for covariates, there was no difference in associated mortality risk between L2TC and L3TC patients.
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March 2021

Fat embolism syndrome in blunt trauma patients with extremity fractures.

J Orthop 2020 Sep-Oct;21:475-480. Epub 2020 Sep 6.

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

Objective: This study sought to provide a national, descriptive analysis to determine fat embolism syndrome (FES) risk factors, hypothesizing that femur fractures and multiple fractures are associated with an increased risk.

Methods: The Trauma Quality Improvement Program was queried (2010-2016) for patients with extremity fractures. A multivariable logistic regression analysis model was used.

Results: From 324,165 patients, 116 patients (0.04%) were diagnosed with FES. An age ≤30, closed femur fracture, and multiple long bone fractures were associated with an increased risk of FES.

Conclusion: Future research to validate these findings and develop a clinical risk stratification tool appears warranted.
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http://dx.doi.org/10.1016/j.jor.2020.08.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923246PMC
September 2020

Outcomes and Mortality Among Adults Hospitalized With COVID-19 at US Medical Centers.

JAMA Netw Open 2021 03 1;4(3):e210417. Epub 2021 Mar 1.

Department of Medicine, University of California, Irvine Medical Center, Orange.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.0417DOI Listing
March 2021

A Dual Pandemic: The Influence of Coronavirus Disease 2019 on Trends and Types of Firearm Violence in California, Ohio, and the United States.

J Surg Res 2021 07 2;263:24-33. Epub 2021 Feb 2.

Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California Irvine, Orange, California. Electronic address:

Background: This study sought to determine the impact of coronavirus disease 2019 stay-at-home (SAH) and reopening orders on trends and types of firearm violence in California, Ohio, and the United States, hypothesizing increased firearm violence after SAH.

Materials And Methods: Retrospective data (January 1, 2018, to July 31, 2020) on firearm incidents/injuries/deaths and types of firearm violence were obtained from the Gun Violence Archive. The periods for SAH and reopening for the US were based on dates for California. Ohio dates were based on Ohio's timeline. Mann-Whitney U analyses compared trends and types of daily firearm violence per 100,000 legal firearm owners across 2018-2020 periods.

Results: In California, SAH and reopening orders had no effect on firearm violence in 2020 compared with 2018 and 2019 periods, respectively. In Ohio, daily median firearm deaths increased during 2020 SAH compared with 2018 and 2019 and firearm incidents and injuries increased during 2020 reopening compared with 2018, 2019 and 2020 SAH. In the United States, during 2020, SAH firearm deaths increased compared with historical controls and firearm incidents, deaths and injuries increased during 2020 reopening compared with 2018, 2019 and 2020 SAH (all P < 0.05). Nationally, when compared with 2018 and 2019, 2020 SAH had increased accidental shootings deaths with a decrease in defensive use, home invasion, and drug-involved incidents.

Conclusions: During 2020 SAH, the rates of firearm violence increased in Ohio and the United States but remained unchanged in California. Nationally, firearm incidents, deaths and injuries also increased during 2020 reopening versus historical and 2020 SAH data. This suggests a secondary "pandemic" as well as a "reopening phenomenon," with increased firearm violence not resulting from self-defense.
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July 2021

Isolated Thoracic Injury Patients With Rib Fractures Undergoing Rib Fixation Have Improved Mortality.

J Surg Res 2021 Jun 16;262:197-202. Epub 2021 Feb 16.

Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California.

Background: Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF.

Materials And Methods: The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed.

Results: From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF.

Conclusions: The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay.
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June 2021

A national analysis of pediatric firearm violence and the effects of race and insurance status on risk of mortality.

Am J Surg 2021 Jan 6. Epub 2021 Jan 6.

University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA. Electronic address:

Objectives: To perform a national analysis of pediatric firearm violence (PFV), hypothesizing that black and uninsured patients would have higher risk of mortality.

Methods: The Trauma Quality Improvement Program (2014-2016) was queried for PFV patients ≤16 years-old. Multivariable logistic regression models on all patients and a subset excluding severe brain injuries were performed.

Results: The PFV mortality rate was 11.2%. 66.5% of PFV patients were black (p < 0.001). Deceased patients were more likely to be uninsured (14.5% vs. 5.3%, p < 0.001). Black race was an associated risk factor for mortality in patients without severe brain injury (OR 5.26, CI 1.00-27.47, p = 0.049) but not for the overall population (OR 1.32, CI 0.68-2.56, p = 0.39).

Conclusion: Nearly two-thirds of PFV patients were black. Contrary to previous studies, black and uninsured pediatric patients did not have an increased risk of mortality overall. However, in a subset of patients without severe brain injury, black race was associated with increased mortality risk.

Summary: Between 2014 and 2016 the mortality rate for pediatric firearm violence (PFV) in children 16 years and younger was 11.2%. Although two-thirds of PFV patients were black, black race and lack of insurance were not risk factors of mortality for the overall population. Once patients with severe brain injury were excluded, black race and became associated with an increased risk of mortality.
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January 2021

Characteristics of survivors of civilian public mass shootings: An Eastern Association for the Surgery of Trauma multicenter study.

J Trauma Acute Care Surg 2021 04;90(4):652-658

From the Center for Trauma and Critical Care, Department of Surgery (B.S., L.R., R.A., J.M.E.), Department of Emergency Medicine (E.R.S.), and Emergency Medical Services Program (G.S.), The George Washington University School of Medicine and Health Sciences, Washington, DC; Department of Surgery (J.N.), University of California, Irvine, Orange, California; Department of Surgery (R.M., E.C., S.U.), University of Colorado, Denver, Colorado; Department of Surgery (B.R.H.R.), Harborview Medical Center, University of Washington, Seattle, Washington; Department of Surgery (P.J.C.), University of Nevada, Las Vegas, Las Vegas, Nevada; Department of Surgery (I.S.), Ryder Trauma Center, University of Miami, Miami, Florida; Department of Surgery (B.J.), University of Arizona, Tucson, Arizona; Department of Surgery (J.G.), Hartford Hospital, Hartford, Connecticut; and Department of Surgery (J.B.), Broward Health, Miami, Florida.

Background: Firearm injury remains a public health crisis. Whereas there have been studies evaluating causes of death in victims of civilian public mass shootings (CPMSs), there are no large studies evaluating injuries sustained and treatments rendered in survivors. The purpose of this study was to describe these characteristics to inform ideal preparation for these events.

Methods: A multicenter, retrospective study of CPMS survivors who were treated at designated trauma centers from July 1, 1999 to December 31, 2017, was performed. Prehospital and hospital variables were collected. Data are reported as median (25th percentile, 75th percentile interquartile range), and statistical analyses were carried out using Mann-Whitney U, χ2, and Kruskal-Wallis tests. Patients who died before discharge from the hospital were excluded.

Results: Thirty-one events involving 191 patients were studied. The median number of patients seen per event was 20 (5, 106), distance to each hospital was 6 (6, 10) miles, time to arrival was 56 (37, 90) minutes, number of wounds per patient was 1 (1, 2), and Injury Severity Score was 5 (1, 17). The most common injuries were extremity fracture (37%) and lung parenchyma (14%). Twenty-nine percent of patients did not receive paramedic-level prehospital treatment. Following arrival to the hospital, 27% were discharged from the emergency department, 32% were taken directly to the operating room/interventional radiology, 16% were admitted to the intensive care unit, and 25% were admitted to the ward. Forty percent did not require advanced treatment within 12 hours. The most common operations performed within 12 hours of arrival were orthopedic (15%) and laparotomy (15%). The most common specialties consulted were orthopedics (38%) and mental health (17%).

Conclusion: Few CPMS survivors are critically injured. There is significant delay between shooting and transport. Revised triage criteria and a focus on rapid transport of the few severely injured patients are needed.

Level Of Evidence: Therapeutic/care management, level IV.
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April 2021

Characteristics of survivors of civilian public mass shootings: An Eastern Association for the Surgery of Trauma multicenter study.

J Trauma Acute Care Surg 2021 04;90(4):652-658

From the Center for Trauma and Critical Care, Department of Surgery (B.S., L.R., R.A., J.M.E.), Department of Emergency Medicine (E.R.S.), and Emergency Medical Services Program (G.S.), The George Washington University School of Medicine and Health Sciences, Washington, DC; Department of Surgery (J.N.), University of California, Irvine, Orange, California; Department of Surgery (R.M., E.C., S.U.), University of Colorado, Denver, Colorado; Department of Surgery (B.R.H.R.), Harborview Medical Center, University of Washington, Seattle, Washington; Department of Surgery (P.J.C.), University of Nevada, Las Vegas, Las Vegas, Nevada; Department of Surgery (I.S.), Ryder Trauma Center, University of Miami, Miami, Florida; Department of Surgery (B.J.), University of Arizona, Tucson, Arizona; Department of Surgery (J.G.), Hartford Hospital, Hartford, Connecticut; and Department of Surgery (J.B.), Broward Health, Miami, Florida.

Background: Firearm injury remains a public health crisis. Whereas there have been studies evaluating causes of death in victims of civilian public mass shootings (CPMSs), there are no large studies evaluating injuries sustained and treatments rendered in survivors. The purpose of this study was to describe these characteristics to inform ideal preparation for these events.

Methods: A multicenter, retrospective study of CPMS survivors who were treated at designated trauma centers from July 1, 1999 to December 31, 2017, was performed. Prehospital and hospital variables were collected. Data are reported as median (25th percentile, 75th percentile interquartile range), and statistical analyses were carried out using Mann-Whitney U, χ2, and Kruskal-Wallis tests. Patients who died before discharge from the hospital were excluded.

Results: Thirty-one events involving 191 patients were studied. The median number of patients seen per event was 20 (5, 106), distance to each hospital was 6 (6, 10) miles, time to arrival was 56 (37, 90) minutes, number of wounds per patient was 1 (1, 2), and Injury Severity Score was 5 (1, 17). The most common injuries were extremity fracture (37%) and lung parenchyma (14%). Twenty-nine percent of patients did not receive paramedic-level prehospital treatment. Following arrival to the hospital, 27% were discharged from the emergency department, 32% were taken directly to the operating room/interventional radiology, 16% were admitted to the intensive care unit, and 25% were admitted to the ward. Forty percent did not require advanced treatment within 12 hours. The most common operations performed within 12 hours of arrival were orthopedic (15%) and laparotomy (15%). The most common specialties consulted were orthopedics (38%) and mental health (17%).

Conclusion: Few CPMS survivors are critically injured. There is significant delay between shooting and transport. Revised triage criteria and a focus on rapid transport of the few severely injured patients are needed.

Level Of Evidence: Therapeutic/care management, level IV.
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April 2021

Regional, Racial, and Mortality Disparities Associated With Neurosurgeon Staffing at Level I Trauma Centers.

Am Surg 2020 Dec 30:3134820983187. Epub 2020 Dec 30.

Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, 218539University of California, CA, USA.

Background: Traumatic brain injury (TBI) occurs in approximately 30% of trauma patients. Because neurosurgeons hold expertise in treating TBI, increased neurosurgical staffing may improve patient outcomes. We hypothesized that TBI patients treated at level I trauma centers (L1TCs) with ≥3 neurosurgeons have a decreased risk of mortality vs. those treated at L1TCs with <3 neurosurgeons.

Methods: The Trauma Quality Improvement Program database (2010-2016) was queried for patients ≥18 years with TBI. Patient characteristics and mortality were compared between ≥3 and <3 neurosurgeon-staffed L1TCs. A multivariable logistic regression analysis was used to identify risk factors associated with mortality.

Results: Traumatic brain injury occurred in 243 438 patients with 5188 (2%) presenting to L1TCs with <3 neurosurgeons and 238 250 (98%) to L1TCs with ≥3 neurosurgeons. Median injury severity score (ISS) was similar between both groups (17, = .09). There were more Black (37% vs. 12%, < .001) and Hispanic (18% vs. 12%, < .001) patients in the <3 neurosurgeon group. Nearly 60% of L1TCs with <3 neurosurgeons are found in the South. Mortality was higher in the <3 vs. the ≥3 group (12% vs. 10%, < .001). Patients treated in the <3 neurosurgeon group had a higher risk for mortality than those treated in the ≥3 neurosurgeon group (odds ratio (OR) 1.13, 95% confidence intervals (CI) 1.01-1.26, = .028).

Discussion: There exists a significant racial disparity in access to neurosurgeon staffing with additional disparities in outcomes based on staffing. Future efforts are needed to improve this chasm of care that exists for trauma patients of color.
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December 2020

Racial and Sex Disparities in Trauma Outcomes Based on Geographical Region.

Am Surg 2020 Dec 9:3134820960063. Epub 2020 Dec 9.

Department of Surgery, Division of Trauma and Surgical Critical Care, 8788University of California, Irvine, USA.

Objectives: Disparities in outcomes among trauma patients have been shown to be associated with race and sex. The purpose of this study was to analyze racial and sex mortality disparities in different regions of the United States, hypothesizing that the risk of mortality among black and Asian trauma patients, compared to white trauma patients, will be similar within all regions in the United States.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for adult trauma patients, separating by U.S. Census regions. Multivariable logistic regression analyses were performed for each region, controlling for known predictors of morbidity and mortality in trauma.

Results: Most trauma patients were treated in the South (n = 522 388, 40.7%). After risk adjustment, black trauma patients had a higher associated risk of death in all regions, except the Northeast, compared to white trauma patients. The highest associated risk of death for blacks (vs. whites) was in the Midwest (odds ratio [OR] 1.30, < .001). Asian trauma patients only had a higher associated risk of death in the West (OR 1.39, < .001). Male trauma patients, compared to women, had an increased associated risk of mortality in all four regions.

Discussion: This study found major differences in outcomes among different races within different regions of the United States. There was also both an increased rate and associated risk of mortality for male patients in all regions. Future prospective studies are needed to identify what regional differences in trauma systems including population density, transport times, hospital access, and other trauma resources explain these findings.
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December 2020

Risk Factors for Appendiceal Cancer After Appendectomy.

Am Surg 2020 Dec 9:3134820960077. Epub 2020 Dec 9.

Department of Surgery, 30133University of California, Orange, CA, USA.

Background: Appendiceal cancer (AC) is a rare malignancy usually diagnosed incidentally after appendectomy. Risk factors for AC are poorly understood. We sought to provide a descriptive analysis for patients with AC discovered after appendectomy for acute appendicitis (AA).

Methods: The 2016-2017 American College of Surgeons-National Surgical Quality Improvement Program Procedure-Targeted Appendectomy database was queried for adult patients who underwent appendectomy for image-suspected AA. Patients with pathology consistent with AA were compared to patients found to have AC. A multivariable logistic regression model was used for analysis.

Results: From 21 058 patients, 203 (1.0%) were found to have AC on pathology. Compared to patients with AA, patients with AC were older (median, 48 vs. 40 years old, < .001). The AA group had a similar rate of perforated appendix compared to the AC group (16.3% vs. 13.4% = .32). After adjusting for covariates, associated risk factors for AC were: age ≥65 years old (odds ratio (OR) 2.25, 1.5-3.38, < .001), absence of leukocytosis (OR 1.58, 1.16-2.17, = .004), and operative time ≥1 hour (OR 1.57, 1.14-2.16, = .006). Gender, race, and history of smoking were not independent associated risk factors for AC.

Conclusion: The incidence of AC after appendectomy for suspected AA is approximately 1% in a large national analysis. These factors may be used to help identify patients at higher risk for AC after appendectomy.
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December 2020

Pediatric burn-trauma patients have increased length of stay compared to trauma-only patients: A propensity matched analysis.

Burns 2021 02 8;47(1):78-83. Epub 2020 May 8.

University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.

Background: Trauma is the leading cause of mortality in children. Burn injury involves intensive resources, especially in pediatric patients. We hypothesized that among pediatric trauma patients, combined burn-trauma (BT) patients have increased length of stay (LOS) and mortality compared to trauma-only (T) patients.

Methods: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried and BT patients were 1:2 propensity-score-matched to T patients based on age, gender, hypotension on admission, injury type and severity.

Results: 93 BT patients were matched to 186 T patients. There were no differences in matched characteristics. BT patients had a longer median LOS (4 vs 2 days, p<0.001) with no difference in mortality (1.1% vs 1.1%, p=1.00), intensive care unit (ICU) LOS (3 vs 3 days, p=0.55), or complications including decubitus ulcer (0% vs 1.1%, p=0.32), deep vein thrombosis (0% vs 0.5%, p=0.48), extremity compartment syndrome (1.1% vs 0%, p=0.16), and urinary tract infection (1.1% vs 1.1%, p=1.00).

Conclusion: Pediatric BT patients had twice the LOS compared to a matched group of pediatric T patients. There was no difference between the cohorts in ICU LOS, complications or mortality rate. When evaluating risk-stratified quality metrics such as LOS, concomitant burn injury should be incorporated.
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February 2021

New York State and the Nation: Trends in Firearm Purchases and Firearm Violence During the COVID-19 Pandemic.

Am Surg 2021 May 24;87(5):690-697. Epub 2020 Nov 24.

Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Orange, CA, USA.

Background: The impacts of social stressors on violence during the coronavirus disease 2019 (COVID-19) pandemic are unknown. We hypothesized that firearm purchases and violence would increase surrounding the pandemic. This study determined the impact of COVID-19 and shelter-in-place (SIP) orders on firearm purchases and incidents in the United States (US) and New York State (NYS).

Methods: Scatterplots reflected trends in firearm purchases, incidents, and deaths over a 16-month period (January 2019 to April 2020). Bivariate comparisons of SIP and non-SIP jurisdictions before and after SIP (February 2020 vs. April 2020) and April 2020 vs. April 2019 were performed with the Mann-Whitney U test.

Results: The incidence of COVID-19 in the US increased between February and April 2020 from 24 to 1 067 660 and in NYS from 0 to 304 372. When comparing February to March to April in the US, firearm purchases increased 33.6% then decreased 22.0%, whereas firearm incidents increased 12.2% then again increased by 3.6% and firearm deaths increased 23.8% then decreased in April by 3.8%. In NYS, comparing February to March to April 2020, firearm purchases increased 87.6% then decreased 54.8%, firearm incidents increased 110.1% then decreased 30.8%, and firearm deaths increased 57.1% then again increased by 6.1%. In both SIP and non-SIP jurisdictions, April 2020 firearm purchases, incidents, deaths, and injuries were similar to April 2019 and February 2020 (all = NS).

Discussion: Coronavirus disease 2019-related stressors may have triggered an increase in firearm purchases nationally and within NYS in March 2020. Firearm incidents also increased in NYS. SIP orders had no effect on firearm purchases and firearm violence.
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May 2021

Predictors of Anastomotic Leak After Esophagectomy for Cancer: Not All Leaks Increase Mortality.

Am Surg 2020 Nov 24:3134820956329. Epub 2020 Nov 24.

Department of Surgery, University of California, Irvine, Orange, CA, USA.

Background: The impact of preoperative chemotherapy/radiation on esophageal anastomotic leaks (ALs) and the correlation between AL severity and mortality risk have not been fully elucidated. We hypothesized that lower severity ALs have a similar risk of mortality compared to those without ALs, and preoperative chemotherapy/radiation increases AL risk.

Methods: The 2016-2017 American College of Surgeons National Surgical Quality Improvement Program's procedure-targeted esophagectomy database was queried for patients undergoing any esophagectomy for cancer. A multivariable logistic regression analysis was performed for risk of ALs.

Results: From 2042 patients, 280 (13.7%) had ALs. AL patients requiring intervention had increased mortality risk including those requiring reoperation, interventional procedure, and medical therapy ( < .05). AL patients requiring no intervention had similar mortality risk compared to patients without ALs ( > .05). Preoperative chemotherapy/radiation was not predictive of ALs ( > .05).

Conclusion: Preoperative chemotherapy/radiation does not contribute to risk for ALs after esophagectomy. There is a stepwise increased risk of 30-day mortality for ALs requiring increased invasiveness of treatment.
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November 2020
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