Publications by authors named "Kenji Inaba"

661 Publications

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

CONTEMPORARY UTILITY OF DIAGNOSTIC PERITONEAL ASPIRATION IN TRAUMA.

J Trauma Acute Care Surg 2021 Apr 8. Epub 2021 Apr 8.

Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA.

Background: Focused Assessment with Sonography for Trauma (FAST) has supplanted Diagnostic Peritoneal Lavage (DPL) as the preferred bedside evaluation for traumatic hemoperitoneum. Diagnostic Peritoneal Aspiration (DPA) is a simpler, faster modification of DPL with an unclear role in contemporary practice. This study delineated modern roles for DPA and defined its diagnostic yield.

Methods: All trauma patients presenting to our Level I center who underwent DPA were included (May 2015-May 2020). Demographics, comorbidities, clinical/injury data, and outcomes were collected. The diagnostic yield and accuracy of DPA were calculated against the gold standard of hemoperitoneum at exploratory laparotomy or CT scan.

Results: In total, 41 patients underwent DPA, typically after blunt trauma (n=37, 90%). Patients were almost exclusively hypotensive (n=20, 49%) or in arrest (n=18, 44%). Most patients had an equivocal or negative FAST and hypotension or return of spontaneous circulation after resuscitative thoracotomy (n=32, 78%); or had a positive FAST and known cirrhosis (n=4, 10%). In two patients (5%), one obese, the catheter failed to access the peritoneal cavity. DPA sensitivity, specificity, PPV, and NPV were 80%, 100%, 100%, and 90%, with an accuracy of 93%. One (2%) complication, a small bowel injury, occurred.

Conclusion: Despite near ubiquitous FAST availability, DPA remains important in diagnosing or excluding hemoperitoneum with exceedingly low rates of failure and complications. DPA is most conclusive when positive, without false positives in this study. DPA was utilized most among blunt hypotensive or post-arrest patients who had an equivocal or negative FAST, in whom the preliminary diagnosis of hemoperitoneum is a critically important decision-making branch point.

Level Of Evidence: III.

Study Type: Prognostic and Epidemiological.
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http://dx.doi.org/10.1097/TA.0000000000003232DOI Listing
April 2021

Predicting Success of REBOA: Timing supersedes variable techniques in predicting patient survival.

J Trauma Acute Care Surg 2021 Jun 4. Epub 2021 Jun 4.

Denver Health Medical Center, Department of Surgery, Denver, Colorado University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland University of Southern California, Department of Surgery, Los Angeles, CA, USA. University of Washington School of Medicine, Department of Surgery, Seattle, WA Texas Health Science Center's McGovern Medical School, Department of Surgery at the University, Houston, Texas Colorado School of Public Health, Aurora, Colorado.

Background: REBOA is used for temporary aortic occlusion of trauma patients in the management of non-compressible hemorrhage. Previous studies have focused on how to properly perform REBOA in the trauma environment to improve survival rates, but high grade evidence defining the ideal patient population does not yet exist. This posthoc analysis of the Emergent Truncal Hemorrhage Control Study seeks to identify the most important clinical factors for physicians to consider when selecting for REBOA candidates and their potential survival following REBOA.

Methods: Post hoc analysis of a large multicenter, prospective observational study conducted at six Level 1 Trauma centers, 2017-2018. An onsite data collector documented all timepoints for REBOA patients since admission. Candidate predictors were: demographics, injury severity, physiology pre, during and post procedure, CPR, REBOA-specific variables (time to procedure, procedure-related time intervals, access site, technique, sheath size, catheter length, balloon volume, deployment zone). Predictive models for survival at three different timepoints along the trauma triage and REBOA process timeline ("Admission", "REBOA Initiation" and "Postaortic Occlusion") were devised by logistic regression.

Results: 88 patients had REBOA placement. The "Admission" model selected age, GCS, and admission SBP as significant predictors of survival (AUC 0.86; 95% CI 0.77-0.94). The "REBOA Initiation" and "After Aortic Occlusion" models selected age, GCS, and the SBP measured just prior to balloon inflation as predictors for survival (AUC 0.87 with 95% CI 0.78-0.97 and AUC as 0.90 with 95% CI 0.81-0.99, respectively). No REBOA procedural variables were identified as predictors of patient survival.

Conclusions: Only patient-specific criteria of age, neurologic status, and severity of shock predicted survival. The hemodynamic stability of the patient at the time REBOA is initiated is more important than how REBOA is initiated. These findings suggest that earlier preparation for REBOA placement may be a key to improved survival.

Level Of Evidence: Level III Prospective Observational Study.
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http://dx.doi.org/10.1097/TA.0000000000003307DOI Listing
June 2021

Ca Regulates ERp57-Calnexin Complex Formation.

Molecules 2021 May 11;26(10). Epub 2021 May 11.

Frontier Research Institute for Interdisciplinary Sciences, Tohoku University, 6-3 Aramakiaza Aoba, Aoba-ku, Sendai 980-8578, Japan.

ERp57, a member of the protein disulfide isomerase family, is a ubiquitous disulfide catalyst that functions in the oxidative folding of various clients in the mammalian endoplasmic reticulum (ER). In concert with ER lectin-like chaperones calnexin and calreticulin (CNX/CRT), ERp57 functions in virtually all folding stages from co-translation to post-translation, and thus plays a critical role in maintaining protein homeostasis, with direct implication for pathology. Here, we present mechanisms by which Ca regulates the formation of the ERp57-calnexin complex. Biochemical and isothermal titration calorimetry analyses revealed that ERp57 strongly interacts with CNX via a non-covalent bond in the absence of Ca. The ERp57-CNX complex not only promoted the oxidative folding of human leukocyte antigen heavy chains, but also inhibited client aggregation. These results suggest that this complex performs both enzymatic and chaperoning functions under abnormal physiological conditions, such as Ca depletion, to effectively guide proper oxidative protein folding. The findings shed light on the molecular mechanisms underpinning crosstalk between the chaperone network and Ca.
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http://dx.doi.org/10.3390/molecules26102853DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8151781PMC
May 2021

Telemedicine Experience of General Surgery Trainees: Impact on Patient Care and Education.

Am Surg 2021 May 28:31348211023402. Epub 2021 May 28.

Department of Surgery, Keck School of Medicine, 5116University of Southern California, Los Angeles, CA, USA.

Objective: The COVID-19 pandemic has had a significant impact on patient care, including the increased utilization of contact-free clinic visits using telemedicine. We looked to assess current utilization of, experience with, and opinions regarding telemedicine by general surgery residents at an academic university-based surgical training program.

Design: A response-anonymous 19-question survey was electronically distributed to all general surgery residents at a single academic university-based general surgery residency program.

Setting: University of Southern California (USC) general surgery residency participants: Voluntarily participating general surgery residents at the University of Southern California.

Results: The response rate from USC general surgery residents was 100%. A majority of residents (76%) had utilized either video- or telephone-based visits during their careers. No resident had undergone formal training to provide telemedicine, although most residents indicated a desire for training (57.1%) and acknowledged that telemedicine should be a part of surgical training (75.6%). A wide variety of opinions regarding the educational experience of residents participating in telemedicine visits was elicited.

Conclusions: The COVID-19 pandemic brought telemedicine to the forefront as an integral part of future patient care, including for surgical patients. Additional investigations into nationwide telemedicine exposure and practice among United States general surgery residencies is imperative, and the impact of the implementation of telemedicine curricula on general surgery resident telemedicine utilization, comfort with telemedicine technology, and patient outcomes are further warranted.

Competencies: Practice-based learning, systems-based practice, interpersonal and communication skills.
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http://dx.doi.org/10.1177/00031348211023402DOI Listing
May 2021

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient.

J Surg Res 2021 May 23;266:284-291. Epub 2021 May 23.

Division of Acute Care Surgery, University of Southern California; Los Angeles, CA.

Background: The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes.

Methods: We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality.

Results: Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts.

Conclusion: Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.
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http://dx.doi.org/10.1016/j.jss.2021.04.009DOI Listing
May 2021

The impact of delayed time to first CT head on functional outcomes after blunt head trauma with moderately depressed GCS.

Eur J Trauma Emerg Surg 2021 May 14. Epub 2021 May 14.

Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA.

Purpose: Recent work suggests patients with moderately depressed Glasgow Coma Scale (GCS) score in the Emergency Department (ED) who do not undergo immediate head CT (CTH) have delayed neurosurgical intervention and longer ED stay. The present study objective was to determine the impact of time to first CTH on functional neurologic outcomes in this patient population.

Methods: Blunt trauma patients presenting to our Level I trauma center (11/2015-10/2019) with first ED GCS 9-12 were retrospectively identified and included. Transfers and those with extracranial AIS ≥ 3 were excluded. The study population was stratified into Immediate (≤ 1 h) and Delayed (1-6 h) CTH groups based on time from ED arrival to first CTH. Outcomes included functional outcomes at hospital discharge based on the Modified Rankin Scale (mRS).

Results: After exclusions, 564 patients were included: 414 (73%) with Immediate CTH and 150 (27%) Delayed CTH. Both groups arrived with median GCS 11 and alcohol/drug intoxication did not differ (p > 0.05). AIS Head/Neck was comparable (3[3-4] vs. 3[3-3], p = 0.349). Time to ED disposition decision and ED exit were significantly shorter after Immediate CTH (2.8[1.5-5.3] vs. 5.2[3.6-7.5]h, p < 0.001 and 5.5[3.3-8.9] vs. 8.1[5.2-11.7]h, p < 0.001). Functional outcomes were slightly worse after Immediate CTH (mRS 2[1-4] vs. 2[1-3], p = 0.002). Subgroup analysis of patients requiring neurosurgical intervention demonstrated a greater proportion of moderately disabled patients with a lower proportion of severely disabled or dead patients after Immediate CTH as compared to Delayed CTH (51 vs. 20%, p = 0.063 and 35 vs. 60%, p = 0.122).

Conclusions: Immediate CTH shortened time to disposition decision out of the ED and ED exit. Patients requiring neurosurgical intervention after Immediate CTH had improved functional outcomes when compared to those undergoing Delayed CTH. These differences did not reach statistical significance in this single-center study and, therefore, a large, multicenter study is the next step in demonstrating the potential functional outcomes benefit of Immediate CTH after blunt head trauma.
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http://dx.doi.org/10.1007/s00068-021-01677-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8121018PMC
May 2021

Increased Incidence of COVID-19 Infections Amongst Interpersonal Violence Patients.

J Surg Res 2021 Apr 30;266:62-68. Epub 2021 Apr 30.

Division of Acute Care Surgery, University of Southern California, Los Angeles, California.

Objective: To investigate whether any specific acute care surgery patient populations are associated with a higher incidence of COVID-19 infection.

Background: Acute care providers may be exposed to an increased risk of contracting the COVID-19 infection since many patients present to the emergency department without complete screening measures. However, it is not known which patients present with the highest incidence.

Methods: All acute care surgery (ACS) patients who presented to our level I trauma center between March 19, 2020, and September 20, 2020 and were tested for COVID-19 were included in the study. The patients were divided into two cohorts: COVID positive (+) and COVID negative (-). Patient demographics, type of consultation (emergency general surgery consults [EGS], interpersonal violence trauma consults [IPV], and non-interpersonal violence trauma consults [NIPV]), clinical data and outcomes were analyzed. Univariate and multivariate analyses were used to compare differences between the groups.

Results: In total, 2177 patients met inclusion criteria. Of these, 116 were COVID+ (5.3%) and 2061 were COVID- (94.7%). COVID+ patients were more frequently Latinos (64.7% versus 61.7%, P = 0.043) and African Americans (18.1% versus 11.2%, P < 0.001) and less frequently Caucasian (6.0% versus 14.1%, P < 0.001). Asian/Filipino/Pacific Islander (7.8% versus 7.2%, P = 0.059) and Native American/Other/Unknown (3.4% versus 5.8%, P = 0.078) groups showed no statistical difference in COVID incidence. Mortality, hospital and ICU lengths of stay were similar between the groups and across patient populations stratified by the type of consultation. Logistic regression demonstrated higher odds of COVID+ infection amongst IPV patients (OR 2.33, 95% CI 1.62-7.56, P < 0.001) compared to other ACS consultation types.

Conclusion: Our findings demonstrate that victims of interpersonal violence were more likely positive for COVID-19, while in hospital outcomes were similar between COVID-19 positive and negative patients.

Level Of Evidence: Level III, Prognostic and Epidemiological.
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http://dx.doi.org/10.1016/j.jss.2021.04.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086826PMC
April 2021

Extracorporeal support for trauma: A trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome.

Am J Emerg Med 2021 Apr 30;48:170-176. Epub 2021 Apr 30.

Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, United States of America.

Introduction: The use of extracorporeal membrane oxygenation (ECMO) in trauma patients with severe acute respiratory distress syndrome (ARDS) continues to evolve. The objective of this study was to perform a comparative analysis of trauma patients with ARDS who received ECMO to a propensity matched cohort of patients who underwent conventional management.

Methods: The Trauma Quality Improvement Program (TQIP) database was queried from 2013 to 2016 for all patients with ARDS and those who received ECMO. Demographics, as well as clinical, injury, intervention, and outcome data were collected and analyzed. Patients with ARDS were divided into two groups, those who received ECMO and those who did not. A propensity score analysis was performed using the following criteria: age, gender, vital signs (HR, SBP) and GCS on admission, Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) score in several body regions. Outcomes between the groups were subsequently compared using univariate as well as Cox regression analyses. Secondary outcomes such as hospitalization (HLOS), ICU length-of-stay (LOS) and ventilation days stratified for patient demographics, timing of ECMO and anticoagulation status were compared.

Results: Over the 3-year study period, 8990 patients with ARDS were identified from the TQIP registry. Following exclusion, 3680 were included in the final analysis, of which 97 (2.6%) received ECMO. On univariate analysis following matching, patients who underwent ECMO had lower overall hospital mortality (23 vs 50%, p < 0.001) with higher rates of complications (p < 0.005), including longer HLOS. In those undergoing ECMO, early initiation (<7 days) was associated with shorter HLOS, ICU LOS, and fewer ventilator days. No difference was observed between the two groups with regard to anticoagulation.

Conclusion: Extracorporeal membrane oxygenation use in trauma patients with ARDS may be associated with improved survival, especially for young patients with thoracic injuries, early in the course of ARDS. Anticoagulation while on circuit was not associated with increased risk of hemorrhage or mortality, even in the setting of head injuries. The mortality benefit suggested with ECMO comes at the expense of a potential increase in complication rate and prolonged hospitalization.
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http://dx.doi.org/10.1016/j.ajem.2021.04.083DOI Listing
April 2021

Association Between Trimester and Outcomes after Cholecystectomy During Pregnancy.

J Am Coll Surg 2021 Apr 9. Epub 2021 Apr 9.

Division of Upper GI and General Surgery, Department of Surgery, University of Southern California, Los Angeles, CA.

Background: Conventional philosophy promotes the second trimester as the ideal time during pregnancy for cholecystectomy. However, literature supporting this belief is sparse. The purpose of the present study is to examine the association of trimester and clinical outcomes following cholecystectomy during pregnancy.

Study Design: The National Inpatient Sample was queried for pregnant women who underwent cholecystectomy between 10/2015 and 12/2017. Patients were categorized by trimester. Multivariable logistic and continuous outcome regression models were used to evaluate the association of trimester and outcomes including maternal and fetal complications, length of stay, and hospital charges. The primary outcome was Any Complication-a composite of specific clinical complications, each of which were designated as secondary outcomes.

Results: A total of 819 pregnant women satisfied our inclusion criteria. Of these, 217 (26.5%) were in the first trimester, 381 (47.5%) were in the second trimester, and 221 (27.0%) were in the third trimester. The median age was 27 years (interquartile range: 23-31). Compared to second trimester, cholecystectomy during the first trimester was not associated with higher rates of complications (adjusted odds ratio [AOR] 0.88, 95% confidence interval [CI]: 0.47-1.63, p=0.68). However, cholecystectomy during the third trimester was associated with a higher rate of preterm delivery (AOR 7.20, 95% CI: 3.09-16.77, p<0.001) and overall maternal and fetal complications (AOR 2.78, 95% CI: 1.71-4.53, p<0.001). Compared to the second trimester, the third trimester was associated with 21.3% higher total hospital charges (p=0.003).

Conclusion: Our results suggest that cholecystectomy can be performed in the first trimester without significantly increased risk of maternal and fetal complications compared to the second trimester. In contrast, cholecystectomy during pregnancy should not be delayed until the third trimester.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.03.034DOI Listing
April 2021

Factors Associated With General Surgery Residents' Operative Experience During the COVID-19 Pandemic.

JAMA Surg 2021 Apr 30. Epub 2021 Apr 30.

Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.

Importance: The suspension of elective operations in March 2020 to prepare for the COVID-19 surge posed significant challenges to resident education. To mitigate the potential negative effects of COVID-19 on surgical education, it is important to quantify how the pandemic influenced resident operative volume.

Objective: To examine the association of the pandemic with general surgical residents' operative experience by postgraduate year (PGY) and case type and to evaluate if certain institutional characteristics were associated with a greater decline in surgical volume.

Design, Setting, And Participants: This retrospective review included residents' operative logs from 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) from 16 general surgery programs. Data collected included total major cases, case type, and PGY. Faculty completed a survey about program demographics and COVID-19 response. Data on race were not collected. Operative volumes from March to June 2020 were compared with the same period during 2018 and 2019. Data were analyzed using Kruskal-Wallis test adjusted for within-program correlations.

Main Outcome And Measures: Total major cases performed by each resident during the first 4 months of the pandemic.

Results: A total of 1368 case logs were analyzed. There was a 33.5% reduction in total major cases performed in March to June 2020 compared with 2018 and 2019 (45.0 [95% CI, 36.1-53.9] vs 67.7 [95% CI, 62.0-72.2]; P < .001), which significantly affected every PGY. All case types were significantly reduced in 2020 except liver, pancreas, small intestine, and trauma cases. There was a 10.2% reduction in operative volume during the 2019-2020 academic year compared with the 2 previous years (192.3 [95% CI, 178.5-206.1] vs 213.8 [95% CI, 203.6-223.9]; P < .001). Level 1 trauma centers (49.5 vs 68.5; 27.7%) had a significantly lower reduction in case volume than non-level 1 trauma centers (33.9 vs 63.0; 46%) (P = .03).

Conclusions And Relevance: In this study of operative logs of general surgery residents in 16 US programs from 2017 to 2020, the first 4 months of the COVID-19 pandemic was associated with a significant reduction in operative experience, which affected every PGY and most case types. Level 1 trauma centers were less affected than non-level 1 centers. If this trend continues, the effect on surgical training may be even more detrimental.
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http://dx.doi.org/10.1001/jamasurg.2021.1978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087976PMC
April 2021

Increased Use of Prehospital Tourniquet and Patient Survival: Los Angeles Countywide Study.

J Am Coll Surg 2021 Apr 22. Epub 2021 Apr 22.

Departments of Surgery and Emergency Medicine, University of Southern California, Los Angeles, CA.

Background: Recent trends in prehospital tourniquet use remain underreported. In addition, the impact of prehospital tourniquet use on patient survival has not been evaluated in a population-level study. We hypothesized that prehospital tourniquets were used more frequently in Los Angeles County and their use was associated with improved patient survival.

Study Design: This is a retrospective cohort study using a database maintained by the Los Angeles County Emergency Medical Services Agency. We included patients who sustained extremity vascular injuries between October 2015 and July 2019. Patients were divided into the following study groups: prehospital tourniquet and no-tourniquet group. Our primary end point was in-hospital mortality. The secondary outcomes included 4- and 24-hour transfusion requirements and delayed amputation.

Results: A total of 944 patients met our inclusion criteria. Of those, 97 patients (10.3%) had prehospital tourniquets placed. The rate of tourniquet use increased linearly throughout our study period (goodness of fit, p = 0.014). In multivariable analysis, prehospital tourniquet use was significantly associated with improved mortality (adjusted odds ratio 0.32; 95% CI, 0.16 to 0.85; p = 0.032). Similarly, transfusion requirements were significantly lower within 4 hours (regression coefficient -547.76; 95% CI, -762.73 to -283.49; p < 0.001) and 24 hours (regression coefficient -1,389.82; 95% CI, -1,824.88 to -920.97; p < 0.001). There was no significant difference in delayed amputation rates (adjusted odds ratio 1.07; 95% CI, 0.21 to 10.88; p < 0.097).

Conclusions: Prehospital tourniquet use has been on the rise in Los Angeles County. Our results suggest that the use of prehospital tourniquets for extremity vascular injuries is associated with improved patient survival and decreased blood transfusion requirements, without an increase in delayed amputations.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.03.023DOI Listing
April 2021

Current practices and challenges in assessing traumatic hemorrhage: An international survey of trauma care providers.

J Trauma Acute Care Surg 2021 May;90(5):e95-e100

From the Department of Surgery (A.T., T.L., J.L.), The Ottawa Hospital, School of Epidemiology and Public Health (A.T., T.L., M.T.), and Division of Critical Care, Department of Medicine (A.T., S.M.F.), University of Ottawa; Clinical Epidemiology Program (M.T., C.V.), Ottawa Hospital Research Institute; Department of Emergency Medicine (S.M.F., C.V.), University of Ottawa, Ottawa, ON, Canada; Department of Surgery (K.I., D.D.), University of Southern California, Los Angeles, California; Department of Surgery (E.E.M.), University of Denver, Denver, Colorado; Division of Acute Care Surgery, Department of Surgery (E.R.H.), and Department of Anesthesiology and Critical Care, Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine; Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

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http://dx.doi.org/10.1097/TA.0000000000003081DOI Listing
May 2021

A unique leucine-valine adhesive motif supports structure and function of protein disulfide isomerase P5 via dimerization.

Structure 2021 Apr 9. Epub 2021 Apr 9.

Institute of Multidisciplinary Research for Advanced Materials, Tohoku University, 2-1-1 Katahira, Aoba-ku, Sendai, Miyagi 980-8577, Japan. Electronic address:

P5, also known as PDIA6, is a PDI family member involved in the ER quality control. Here, we revealed that P5 dimerizes via a unique adhesive motif contained in the N-terminal thioredoxin-like domain. Unlike conventional leucine zipper motifs with leucine residues every two helical turns on ∼30-residue parallel α helices, this adhesive motif includes periodic repeats of leucine/valine residues at the third or fourth position spanning five helical turns on 15-residue anti-parallel α helices. The P5 dimerization interface is further stabilized by several reciprocal salt bridges and C-capping interactions between protomers. A monomeric P5 mutant with the impaired adhesive motif showed structural instability and local unfolding, and behaved as aberrant proteins that induce the ER stress response. Disassembly of P5 to monomers compromised its ability to inactivate IRE1α via intermolecular disulfide bond reduction and its Ca-dependent regulation of chaperone function in vitro. Thus, the leucine-valine adhesive motif supports structure and function of P5.
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http://dx.doi.org/10.1016/j.str.2021.03.016DOI Listing
April 2021

Distinct roles and actions of protein disulfide isomerase family enzymes in catalysis of nascent-chain disulfide bond formation.

iScience 2021 Apr 9;24(4):102296. Epub 2021 Mar 9.

Institute of Multidisciplinary Research for Advanced Materials, Katahira 2-1-1, Aoba-ku, Tohoku University, Sendai, Miyagi 980-8577, Japan.

The mammalian endoplasmic reticulum (ER) harbors more than 20 members of the protein disulfide isomerase (PDI) family that act to maintain proteostasis. Herein, we developed an system for directly monitoring PDI- or ERp46-catalyzed disulfide bond formation in ribosome-associated nascent chains of human serum albumin. The results indicated that ERp46 more efficiently introduced disulfide bonds into nascent chains with a short segment exposed outside the ribosome exit site than PDI. Single-molecule analysis by high-speed atomic force microscopy further revealed that PDI binds nascent chains persistently, forming a stable face-to-face homodimer, whereas ERp46 binds for a shorter time in monomeric form, indicating their different mechanisms for substrate recognition and disulfide bond introduction. Thus, ERp46 serves as a more potent disulfide introducer especially during the early stages of translation, whereas PDI can catalyze disulfide formation when longer nascent chains emerge out from ribosome.
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http://dx.doi.org/10.1016/j.isci.2021.102296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8024706PMC
April 2021

Hangings: Lessons Learned from the Coroner's Office.

J Surg Res 2021 Apr 5;264:158-162. Epub 2021 Apr 5.

Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, California.

Background: Hangings are an infrequent wounding mechanism among patients arriving alive to hospital but are frequently encountered by the Coroner's Office. It is unclear if classically described hanging injuries, such as the Hangman's fracture, are common among contemporary hangings patients who typically do not suspend from height. This study was undertaken to define patient and injury characteristics after hangings causing death.

Methods: All patients presenting to the Los Angeles County Medical Examiner/Coroner's Office (January 2016 - May 2020) who died by hanging were included. Demographics, psychiatric history, hanging details, autopsy type, and sustained injuries were collected. Data variables were summarized with descriptive statistics and the diagnostic yield of a ligature mark in the diagnosis/exclusion of cervical injuries was calculated.

Results: Over the study, 1,401 patients died by hanging. Patients underwent external exam alone (n = 1,282, 92%), traditional neck autopsy (n = 114, 8%), or traditional neck autopsy plus postmortem computed tomography scan (n = 5, <1%). Home was the most frequent hanging setting (n = 1,028, 73%) followed by public spaces (n = 80, 6%) and jail (n = 28, 2%). The manner of death was almost exclusively suicide (n = 1,395, >99%) and psychiatric disease was common (n = 968, 69%). Of the patients undergoing traditional autopsy, most had a ligature mark (n = 109, 92%) and only 9 (8%) had a cervical injury (hyoid fractures, n = 6, 5%; thyroid cartilage fractures, n = 4, 3%). None had a vertebral fracture/dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of a ligature mark were 100%, 5%, 8%, and 100%.

Conclusions: Hangings are a frequent cause of death in Los Angeles County. Patients typically have a psychiatric history and die almost exclusively from suicide. Hangings commonly occur at home, in public places, and in jail. Injuries were exceedingly rare and no patient sustained a Hangman's fracture, which may be related to the lack of significant suspension with modern hangings.
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http://dx.doi.org/10.1016/j.jss.2021.02.021DOI Listing
April 2021

Prehospital Trauma Care in Disasters and Other Mass Casualty Incidents - A Proposal for Hospital-Based Special Medical Response Teams.

Cureus 2021 Mar 2;13(3):e13657. Epub 2021 Mar 2.

Department of Surgery, Riverside Community Hospital, Riverside, USA.

Current mass casualty incident (MCI) response in the United States calls for rapid deployment of first responders, such as law enforcement, fire, and emergency medical services personnel, to the incident and simultaneous activation of trauma center disaster protocols. Past investigations demonstrated that the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams resulted in improved mortality during routine emergency medical care in Europe and in the combat setting. To date, limited research exists on the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams for civilian MCIs. We proposed the concept of Special Medical Response Teams, which would rapidly deploy advanced trauma-trained physicians and paramedics to deliver a higher level of medical and surgical care in the prehospital setting during civilian mass casualty incidents.
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http://dx.doi.org/10.7759/cureus.13657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016499PMC
March 2021

Temporal profile of the pro- and anti-inflammatory responses to severe hemorrhage in patients with venous thromboembolism: Findings from the PROPPR trial.

J Trauma Acute Care Surg 2021 05;90(5):845-852

From the Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery (B.H.M., M.A.S.), Oregon Health & Science University, Portland, Oregon; Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery (C.E.W., E.E.F.), University of Texas Health Science Center, Houston, Texas; Division of Acute Care Surgery, Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Department of Surgery (M.J.C.), Denver Health Medical Center and the University of Colorado; Denver, Colorado; and Department of Surgery (J.B.H.), University of Alabama at Birmingham, Birmingham, Alabama.

Background: The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial showed that 15% of patients developed venous thromboembolism (VTE) following hemorrhage, but the mechanisms are unknown. Since inflammation is associated with hypercoagulability and thrombosis, our goal was to compare the temporal inflammatory profile following hemorrhagic shock in patients with and without VTE.

Study Design: Secondary analysis was performed on data collected from PROPPR. Blood samples collected at 0 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours following admission were assayed on a 27-target cytokine panel, and compared between VTE (n = 83) and non-VTE (n = 475) patients. p < 0.05 indicated significance.

Results: Over time, both groups exhibited elevations in proinflammatory mediators interleukin (IL)-6, IL-8, IL-10, granulocyte colony-stimulating factor 57, monocyte chemoattractant protein 1 and macrophage inflammatory protein 1β, and anti-inflammatory mediators IL-1ra and IL-10 (p < 0.05 vs. admission). Venous thromboembolism patients showed amplified responses for IL-6 (6-72 hours) and IL-8 (6-24 hours), which peaked at later time points, and granulocyte colony-stimulating factor 57 (12-24 hours), monocyte chemoattractant protein 1 (6-72 hours), and macrophage inflammatory protein-1 β (2-12 hours) (p < 0.05 vs. non-VTE per time point) that peaked at similar time points to non-VTE patients. The anti-inflammatory responses were similar between groups, but the interleukin-mediated proinflammatory responses continued to rise after the peak anti-inflammatory response in the VTE group. The occurrence rate of adverse events was higher in VTE (97%) versus non-VTE (87%, p = 0.009) and was associated with higher inflammation.

Conclusion: Patients with VTE following hemorrhagic shock exhibited a prolonged and amplified proinflammatory responses mediated by select interleukin, chemotactic, and glycoprotein cytokines that are not antagonized by anti-inflammatory mediators. This response is not related to randomization group, injury severity or degree of shock, but may be linked to adverse events.

Level Of Evidence: Prognostic, level III.
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http://dx.doi.org/10.1097/TA.0000000000003088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068582PMC
May 2021

Prehospital Needle Decompression Improves Clinical Outcomes in Helicopter Evacuation Patients With Multisystem Trauma: A Multicenter Study.

J Spec Oper Med 2021 ;21(1):49-54

Background: The utility of prehospital thoracic needle decompression (ND) for tension physiology in the civilian setting continues to be debated. We attempted to provide objective evidence for clinical improvement when ND is performed and determine whether technical success is associated with provider factors. We also attempted to determine whether certain clinical scenarios are more predictive than others of successful improvement in symptoms when ND is performed.

Methods: Prehospital ND data acquired from one air ambulance service serving 79 trauma centers consisted of 143 patients (n = 143; ND attempts = 172). Demographic and clinical outcome data were retrospectively reviewed. Patients were stratified by prehospital characteristics and indications. Objective outcomes were measured as improvement in vital signs, subjective patient assessment, and physical examination findings. Univariate analysis was performed using chi-square for variable proportions and unpaired Student's t-test for variable means; p < .05 was considered statistically significant.

Results: The success rate of ND performed for hypoxia (70.5%) was notably higher than ND performed for hemodynamic instability (20.3%; p < .01) or cardiac arrest (0%; p < .01). Compared to vital sign parameters, clinical examination findings as part of the indication for ND did not reliably predict technical success (p > .52 for all indications). No difference was observed comparing registered nurse versus paramedic (p = .23), diameter of catheter (p > .13 for all), or length of catheter (p = .12).

Conclusion: Prehospital ND should be considered in the appropriate clinical setting. Outcomes are less reliable in cases of cardiopulmonary arrest or hypotension with respiratory symptoms; however, this should not deter prehospital providers from attempting ND when clinically indicated. Additionally, the success rate of prehospital ND does not appear to be related to catheter type or the role of the performing provider.
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March 2021

Determination of optimal deployment strategy for REBOA in patients with non-compressible hemorrhage below the diaphragm.

Trauma Surg Acute Care Open 2021 23;6(1):e000660. Epub 2021 Feb 23.

Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA.

Background: Non-compressible truncal hemorrhage (NCTH) is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control, supporting cardiac and cerebral perfusion prior to definitive hemostasis. Aortic zone selection algorithms vary among institutions. We evaluated the efficacy of an algorithm for REBOA use.

Methods: A multicenter prospective, observational study conducted at six level 1 trauma centers over 12 months. Inclusion criteria were age >15 years with evidence of infradiaphragmatic NCTH needing emergent hemorrhage control within 60 min of ED arrival. An algorithm characterized by the results of focused assessment with sonography in trauma and pelvic X-ray was assessed post hoc for efficacy in a cohort of patients receiving REBOA.

Results: Of the 8166 patients screened, 78 patients had a REBOA placed. 21 patients were excluded, leaving 57 patients for analysis. The algorithm ensures REBOA deployment proximal to hemorrhage source to control bleeding in 98.2% of cases and accurately predicts the optimal REBOA zone in 78.9% of cases. If the algorithm was violated, bleeding was optimally controlled in only 43.8% (p=0.01). Three (75.0%) of the patients that received an inappropriate zone 1 REBOA died, two from multiple organ failure (MOF). All three patients that died with an inappropriate zone 3 REBOA died from exsanguination.

Discussion: This algorithm ensures proximal hemorrhage control and accurately predicts the primary source of hemorrhage. We propose a new algorithm that will be more inclusive. A zone 3 REBOA should not be performed when a zone 1 is indicated by the algorithm as 100% of these patients exsanguinated. MOF, perhaps from visceral ischemia in patients with an inappropriate zone 1 REBOA, may have been prevented with zone 3 placement or limited zone 1 occlusion time.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1136/tsaco-2020-000660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907878PMC
February 2021

Endovascular versus open repair of isolated superficial femoral and popliteal artery injuries.

J Vasc Surg 2021 Mar 5. Epub 2021 Mar 5.

Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif. Electronic address:

Objective: Despite the increasing use of endovascular therapy for traumatic arterial injuries, little is known about the outcomes of endovascular repair of superficial femoral artery (SFA) and popliteal artery (PA) injuries. In the present study, we compared the characteristics and outcomes of endovascular vs open repair of traumatic SFA and PA injuries.

Methods: We performed a retrospective National Trauma Data Bank analysis of trauma patients with a blunt or penetrating injury of the SFA and/or PA who had undergone endovascular or open repair from 2007 to 2014. Multivariate logistic regression was used to compare the outcomes, with propensity score matching used for sensitivity analysis.

Results: The incidence of SFA and PA injuries was 0.2%, with an overall increase in the annual use of endovascular stent repair from 3.2% in 2007 to 7.6% in 2014 (P = .002). A total of 2,873 patients with an isolated SFA and/or PA injury were included in the present study, of whom 163 (5.7%) had undergone endovascular repair. SFA injuries were more frequently treated with endovascular repair (70% vs 27%) and PA injuries were more often associated with open repair (41.1% vs 54.7%). Open repair was more frequently associated with a concomitant femur fracture or knee dislocation (30.7% vs 38.8%; P = .039). Endovascular repair was not associated with worse in-hospital amputation-free survival (AFS) compared with open repair on univariate analysis (91.1% vs 89.7%; P = .573) or multivariate logistic regression (odds ratio [OR], 1.053; 95% confidence interval [CI], 0.551-2.012; P = .876). Propensity score matching revealed that in-hospital mortality was higher (OR, 3.69; 95% CI, 1.37-9.82; P = .01) and fasciotomy was lower (OR, 0.23; 95% CI, 0.14-0.37; P < .001) in the endovascular repair group, with no significant differences in AFS (OR, 0.86; 95% CI, 0.48-1.67; P = .65).

Conclusions: Endovascular repair of SFA and PA injuries has in-hospital AFS comparable to that for open repair, supporting the increasing use of endovascular repair for traumatic SFA and PA injuries in appropriately selected cases. Given the unexpected finding of increased in-hospital mortality after endovascular repair, further studies are necessary to determine the appropriate patient selection and the durability of endovascular repair.
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http://dx.doi.org/10.1016/j.jvs.2021.02.023DOI Listing
March 2021

Practical assessment of different saw types for field amputation: A cadaver-based study.

Am J Emerg Med 2021 Feb 21;45:11-16. Epub 2021 Feb 21.

Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, Los Angeles, CA 90033, USA. Electronic address:

Introduction: Field amputation can be life-saving for entrapped patients requiring surgical extrication. Under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. The aim of this study was to determine the ideal saw, and optimal approach, through bone or joint, for a field amputation.

Methods: This was a prospective cadaver-based study. Four saws (Gigli, manual pruning, electric oscillating and electric reciprocating) were tested in human cadavers. Each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula), previously exposed at a standardized location. The time required for each saw to cut through the bone, the number of attempts required to seat the saw when transecting the bone, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. Additionally, the most effective saw in the through bone assessment was compared to limb amputation using scalpel and scissors for a through joint amputation at the elbow, wrist, knee and ankle. Univariate analysis was used to compare the outcomes between the different saws.

Results: The fastest saw for the through bone amputation was the reciprocating followed by oscillating (2.1 [1.4-3.7] seconds vs 3.0 [1.6-4.9] seconds). The manual pruning (58.8 [25-121] seconds) was the slowest (p = 0.007). Overall, the oscillating saw was superior or equivalent to the other devices in number of attempts (1), slippage (0), quality of bone cut (100% good) and physical space requirements (4500 cm), and was the second fastest. In comparison, a through joint amputation (125.0 [50-147] seconds for scalpel and scissor; 125.5 [86-217] seconds for the oscillating saw) was significantly slower than through bone with the Gigli (p = 0.029), the oscillating (p = 0.029) and the reciprocal saw (p = 0.029).

Conclusions: The speed, precision, safety, space required, as well as the adjustable blade of the oscillating saw make it ideal for a field amputation. A Gigli saw is an excellent backup for when electrical tools cannot be used. Through bone amputation is faster than a through joint amputation.
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http://dx.doi.org/10.1016/j.ajem.2021.02.034DOI Listing
February 2021

Reversal of DOACs in trauma: Questions remain unanswered.

Am J Surg 2021 Feb 18. Epub 2021 Feb 18.

Division of Acute Care Surgery, Department of Surgery, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA 90033, USA. Electronic address:

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http://dx.doi.org/10.1016/j.amjsurg.2021.02.005DOI Listing
February 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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http://dx.doi.org/10.1016/j.jss.2021.01.018DOI Listing
July 2021

Trends in Trauma Admissions During the COVID-19 Pandemic in Los Angeles County, California.

JAMA Netw Open 2021 02 1;4(2):e211320. Epub 2021 Feb 1.

Division of Acute Care Surgery, University of Southern California, Los Angeles.

Importance: Describing the changes in trauma volume and injury patterns during the course of the coronavirus disease 2019 (COVID-19) pandemic could help to inform policy development and hospital resource planning.

Objective: To examine trends in trauma admissions throughout Los Angeles County (LAC) during the pandemic.

Design, Setting, And Participants: In this cohort study, all trauma admissions to the 15 verified level 1 and level 2 trauma centers in LAC from January 1 to June 7, 2020 were reviewed. All trauma admissions from the same period in 2019 were used as historical control. For overall admissions, the study period was divided into 3 intervals based on daily admission trend analysis (January 1 through February 28, March 1 through April 9, April 10 through June 7). For the blunt trauma subgroup analysis, the study period was divided into 3 similar intervals (January 1 through February 27, February 28 through April 5, April 6 through June 7).

Exposures: COVID-19 pandemic.

Main Outcomes And Measures: Trends in trauma admission volume and injury patterns.

Results: A total of 6777 patients in 2020 and 6937 in 2019 met inclusion criteria. Of those admitted in 2020, the median (interquartile range) age was 42 (28-61) years and 5100 (75.3%) were men. Mechanisms of injury were significantly different between the 2 years, with a higher incidence of penetrating trauma and fewer blunt injuries in 2020 compared with 2019 (penetrating: 1065 [15.7%] vs 1065 [15.4%]; blunt: 5309 [78.3%] vs 5528 [79.7%]). Overall admissions by interval in 2020 were 2681, 1684, and 2412, whereas in 2019 they were 2462, 1862, and 2613, respectively. There was a significant increase in overall admissions per week during the first interval (incidence rate ratio [IRR], 1.02; 95% CI, 1.002-1.04; P = .03) followed by a decrease in the second interval (IRR, 0.92; 95% CI, 0.90-0.94; P < .001) and, finally, an increase in the third interval (IRR, 1.05; CI, 1.03-1.07; P < .001). On subgroup analysis, blunt admissions followed a similar pattern to overall admissions, while penetrating admissions increased throughout the study period.

Conclusions And Relevance: In this study, trauma centers throughout LAC experienced a significant change in injury patterns and admission trends during the COVID-19 pandemic. A transient decrease in volume was followed by a quick return to baseline levels. Trauma centers should prioritize maintaining access, capacity, and functionality during pandemics and other national emergencies.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.1320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900857PMC
February 2021

Critical decision points in the management of acute trauma: a practical review.

Int Anesthesiol Clin 2021 Apr;59(2):1-9

Department of Surgery, Division of Trauma and Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California.

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http://dx.doi.org/10.1097/AIA.0000000000000317DOI Listing
April 2021

Utility of the Laboratory Risk Indicator for Necrotizing Fasciitis Score: Comorbid Conditions Do Matter.

Surg Infect (Larchmt) 2021 Feb 5. Epub 2021 Feb 5.

Division of Acute Care Surgery, University of Southern California, Los Angeles, California, USA.

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) has been proposed as a diagnostic tool for necrotizing soft tissue infection (NSTI). However, its utility remains underreported, particularly in patients with comorbid conditions. The purpose of this study was to identify the test characteristics of LRINEC for patients with various comorbid conditions. We conducted a retrospective study including patients with suspected NSTI. Our study patients were then relegated into the subgroups; intravenous drug use (IVDU), end-stage liver disease (ESLD), and diabetes mellitus (DM). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a positive LRINEC score (≥ 6 or 8) were calculated in reference to intra-operative findings or results of the pathologic examination. Area under the curve (AUC) using receiver operating characteristic (ROC) plots were compared between each subgroup and the overall study population using DeLong test. A total of 220 patients were included for the analysis. Overall, the sensitivity was 76%, specificity of 52%, PPV of 32%, and NPV of 88%. The subgroup analysis showed low PPVs in all subgroups. The DM and ESLD groups had a high NPV (90.5% and 88.0%, respectively), whereas NPV in the IVDU group was 70.6%. The AUC and DeLong test for the subgroups were 0.649 (p = 0.902) for ESLD, 0.699 (p = 0.683) for DM, and 0.565 (p = 0.034) for IVDU. The LRINEC can be a useful adjunct to rule out the diagnosis of NSTI with exception of IVDU. In contrast, further diagnostic workup might be still required in those patients with positive LRINEC.
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http://dx.doi.org/10.1089/sur.2020.398DOI Listing
February 2021

Retained bullet fragments after nonfatal gunshot wounds: epidemiology and outcomes.

J Trauma Acute Care Surg 2021 Jun;90(6):973-979

From the Division of Trauma and Critical Care, LAC + USC Medical Center, Los Angeles, California.

Background: With no consensus on the optimal management strategy for asymptomatic retained bullet fragments (RBF), the emerging data on RBF lead toxicity have become an increasingly important issue. There are, however, a paucity of data on the magnitude of this problem. The aim of this study was to address this by characterizing the incidence and distribution of RBF.

Methods: A trauma registry was used to identify all patients sustaining a gunshot wound (GSW) from July 1, 2015, to June 31, 2016. After excluding deaths during the index admission, clinical demographics, injury characteristics, presence and location of RBF, management, and outcomes, were analyzed.

Results: Overall, 344 patients were admitted for a GSW; of which 298 (86.6%) of these were nonfatal. Of these, 225 (75.5%) had an RBF. During the index admission, 23 (10.2%) had complete RBF removal, 35 (15.6%) had partial, and 167 (74.2%) had no removal. Overall, 202 (89.8%) patients with nonfatal GSW were discharged with an RBF. The primary indication for RBF removal was immediate intraoperative accessibility (n = 39, 67.2%). The most common location for an RBF was in the soft tissue (n = 132, 58.7%). Of the patients discharged with an RBF, mean age was 29.5 years (range, 6.1-62.1 years), 187 (92.6%) were me, with a mean Injury Severity Score of 8.6 (range, 1-75). One hundred sixteen (57.4%) received follow-up, and of these, 13 (11.2%) returned with an RBF-related complication [infection (n = 4), pain (n = 7), fracture nonunion (n = 1), and bone erosion (n = 1)], with a mean time to complication of 130.2 days (range, 11-528 days). Four (3.4%) required RBF removal with a mean time to removal of 146.0 days (range, 10-534 days).

Conclusion: Retained bullet fragments are very common after a nonfatal GSW. During the index admission, only a minority are removed. Only a fraction of these are removed during follow-up for complications. As lead toxicity data accumulates, further follow-up studies are warranted.

Level Of Evidence: Prognostic and epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000003089DOI Listing
June 2021

Police Transport for Penetrating Trauma-Lessons From Patients in Philadelphia.

JAMA Netw Open 2021 01 4;4(1):e2035122. Epub 2021 Jan 4.

Department of Surgery, UC Davis Health, Sacramento, California.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.35122DOI Listing
January 2021

Temporary intravascular shunts after civilian arterial injury: A prospective multicenter Eastern Association for the Surgery of Trauma study.

Injury 2021 May 3;52(5):1204-1209. Epub 2021 Jan 3.

Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, 51 North 39th Street, Medical Office Building Suite 120, 19104 Philadelphia, Pennsylvania, USA. Electronic address:

Introduction: We sought to determine the impact of the indication for shunt placement on shunt-related outcomes after major arterial injuries. We hypothesized that a shunt placed for damage control indications would be associated with an increase in shunt-related complications including shunt dislodgement, thrombosis, or distal ischemia.

Patients & Methods: A prospective, multicenter study (eleven level one US trauma centers) of all adult trauma patients undergoing temporary intravascular shunts (TIVS) after arterial injury was undertaken (January 2017-May 2019). Exclusion criteria included age <15years, shunt placement distal to popliteal/brachial arteries, isolated venous shunts, and death before shunt removal. Clinical variables were compared by indication and shunt-related complications. The primary endpoint was TIVS complications (thrombosis, migration, distal ischemia).

Results: The 66 patients who underwent TIVS were primarily young (30years [IQR 22-36]) men (85%), severely injured (ISS 17 [10-25]) by penetrating mechanisms (59%), and had their shunts placed for damage control (41%). After a median SDT of 198min [89-622], 9% experienced shunt-related complications. Compared by shunt placement indication (damage control shunts [n=27] compared to non-damage control shunts [n=39]), there were no differences in gender, mechanism, extremity AIS, MESS score, fractures, or surgeon specialty between the two groups (all p>0.05). Patients with shunts placed for damage control indications had more severe injuries (ISS 23.5 compared to 13; SBP 100 compared to 129; GCS 11 compared to 15; lactate 11.5 compared to 3.6; all p<0.05), and had more frequent shunt complication predictors, but damage control shunts did not have significantly more TIVS complications (11.1% compared to 7.7%, p=0.658). Shunt complication patients were discharged home less often (33% vs 65%; p<0.05) but all survived.

Conclusion: Shunts placed for damage control indications were not associated with shunt complications in this prospective, multicenter study.
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http://dx.doi.org/10.1016/j.injury.2020.12.035DOI Listing
May 2021