Publications by authors named "Matthew Dolich"

70 Publications

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

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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http://dx.doi.org/10.1177/0003134820966290DOI Listing
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

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

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

J Surg Res 2021 06 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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http://dx.doi.org/10.1016/j.jss.2021.01.016DOI Listing
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 Sep 6;222(3):654-658. 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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http://dx.doi.org/10.1016/j.amjsurg.2020.12.049DOI Listing
September 2021

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

Am Surg 2021 Jun 9;87(6):988-993. 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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http://dx.doi.org/10.1177/0003134820960063DOI Listing
June 2021

Risk Factors for Appendiceal Cancer After Appendectomy.

Am Surg 2021 Jun 9;87(6):994-998. 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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http://dx.doi.org/10.1177/0003134820960077DOI Listing
June 2021

University Teaching Trauma Centers: Decreased Mortality but Increased Complications.

J Surg Res 2021 03 24;259:379-386. Epub 2020 Oct 24.

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

Background: Teaching hospitals are often regarded as excellent institutions with significant resources and prominent academic faculty. However, the involvement of trainees may contribute to higher rates of complications. Conflicting reports exist regarding outcomes between teaching and nonteaching hospitals, and the difference among trauma centers is unknown. We hypothesized that university teaching trauma centers (UTTCs) and nonteaching trauma centers (NTTCs) would have a similar risk of complications and mortality.

Methods: We queried the Trauma Quality Improvement Program (2010-2016) for adults treated at UTTCs or NTTCs. A multivariable logistic regression analysis was performed to evaluate the risk of mortality and in-hospital complications, such as respiratory complications (RCs), venous thromboembolisms (VTEs), and infectious complications (ICs).

Results: From 895,896 patients, 765,802 (85%) were treated at UTTCs and 130,094 (15%) at NTTCs. After adjusting for covariates, UTTCs were associated with an increased risk of RCs (odds ratio (OR) 1.33, confidence interval (CI) 1.28-1.37, P < 0.001), VTEs (OR 1.17, CI 1.12-1.23, P < 0.001), and ICs (OR 1.56, CI 1.49-1.64, P < 0.001). However, UTTCs were associated with decreased mortality (OR 0.96, CI 0.93-0.99, P = 0.008) compared with NTTCs.

Conclusions: Our study demonstrates increased associated risks of RCs, VTEs, and ICs, yet a decreased associated risk of in-hospital mortality for UTTCs when compared with NTTCs. Future studies are needed to identify the underlying causative factors behind these differences.
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http://dx.doi.org/10.1016/j.jss.2020.09.020DOI Listing
March 2021

An increasing trend in geriatric trauma patients undergoing surgical stabilization of rib fractures.

Eur J Trauma Emerg Surg 2020 Oct 23. Epub 2020 Oct 23.

Irvine Medical Center, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.

Purpose: The proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18-64 years old) undergoing SSRF.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed.

Results: From 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (p < 0.001) with a geometric-mean-annual increase of 11.5%. GTPs had a lower median injury severity score (18 vs. 22, p < 0.001), but had a higher rate of mortality (4.7% vs. 1.2%, p < 0.001). After controlling for covariates, GTPs had an increased associated risk of mortality (OR 4.80, CI 3.62-6.36, p < 0.001). On a separate multivariate analysis for all trauma patients with isolated chest Abbreviated Injury Scale 3, GTPs were associated with a similar four-fold risk of mortality (OR 4.21, CI 1.98-6.32, p < 0.001).

Conclusion: Spanning 7 years of data, the proportion of GTPs undergoing SSRF increased by over 7%. Although GTPs undergoing SSRF had lesser injuries, their risk of mortality was four times higher than other adult trauma patients undergoing SSRF, which was similar to their increased background risk of mortality. Ultimately, SSRF in GTPs should be considered on an individualized basis with careful attention to risk-benefit ratio.
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http://dx.doi.org/10.1007/s00068-020-01526-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7583690PMC
October 2020

Comparison of surgical fixation and non-operative management in patients with traumatic sternum fracture.

Eur J Trauma Emerg Surg 2020 Oct 19. Epub 2020 Oct 19.

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

Purpose: The incidence of sternal fractures in blunt trauma patients lies between 3 and 7%. The role, timing and indications for surgical management are not well delineated and remain controversial for patients undergoing surgical stabilization of sternum fracture (SSSF). We sought to identify the national rate of SSSF in patients with a sternum fracture hypothesizing patients undergoing SSSF will have a decreased rate of mortality and complications.

Methods: The Trauma Quality Improvement Program (2015-2016) was queried for patients with sternum fracture. Propensity scores were calculated to match patients undergoing SSSF to patients managed non-operatively in a 1:2 ratio using demographic data.

Results: From 9460 patients with a sternum fracture, 114 (1.2%) underwent SSSF. After propensity-matching, 112 SSSF patients were compared to 224 patients undergoing non-operative management (NOM). There were no differences in matched characteristics (all p > 0.05). Compared to patients undergoing NOM, patients undergoing SSSF had an increased median length of stay (LOS) (16 vs. 7 days, p < 0.001), ICU LOS (9.5 vs. 5.5 days, p = 0.016) and ventilator days (8 vs. 5, p = 0.035). The SSSF group had a similar rate of ARDS (2.7% vs. 2.2%, p = 0.80), pneumonia (1.8% vs. 0.9%, p = 0.48) and unplanned intubation (8.9% vs. 5.8%, p = 0.29) but a lower mortality rate (2.7% vs. 11.2%, p = 0.008).

Conclusion: Just over 1% of patients with sternum fracture underwent SSSF in a national analysis. Patients undergoing SSSF had an increased LOS and similar rate of all measured pulmonary complications, however a lower mortality rate compared to patients managed non-operatively.
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http://dx.doi.org/10.1007/s00068-020-01527-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571865PMC
October 2020

Adult Bicycle Collisions: Impact of Helmet Use on Head and Cervical Spine Injury.

J Surg Res 2021 02 9;258:307-313. Epub 2020 Oct 9.

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

Background: No states currently require adult bicycle riders to wear helmets. Opponents of a universal helmet law argue that helmets may cause a greater torque on the neck during collisions, potentially increasing the risk of cervical spine fracture (CSF). This assumption has not been supported by data for motorcyclists. Therefore, we sought to evaluate the risk of CSF and cervical spinal cord injury (CSCI) in helmeted bicyclists (HBs) versus nonhelmeted bicyclists (NHBs) involved in collisions. We hypothesize that in adult HBs, there is an increased incidence of CSF and injury but lower rates of severe head injury and mortality than in NHBs.

Materials And Methods: The Trauma Quality Improvement Program (2010-2016) was queried for adult bicyclists involved in collisions, comparing HBs with NHBs. A multivariable logistic regression model was used for analysis.

Results: Of 25,047 bicyclists, 14,234 (56.8%) were NHBs. NHBs were more often black (13.3% versus 2.3%, P < 0.001) and screened positive for alcohol on admission (25.7% versus 4.6%, P < 0.001). NHBs had lower rates of CSF (17.7% versus 23.7%, P < 0.001) and CSCI (1.1% versus 1.9%, P < 0.001) but higher rates of mortality (4.9% versus 2.2%, P < 0.001) and a higher risk for severe head injury (odds ratio [OR]: 2.26, 2.13-2.40, P < 0.001). After adjusting for covariates, NHBs had a higher risk of mortality (OR: 2.38, 2.00-2.84, P < 0.001) but lower risk of CSF (OR: 0.66 0.62-0.71, P < 0.001) and CSCI (OR: 0.53, 0.42-0.68, P < 0.001).

Conclusions: HBs involved in collisions have a higher risk of CSF and CSCI; however, NHBs have a higher risk of severe head injury and mortality. Consideration for a universal helmet law among bicyclists and ongoing research regarding helmet development is needed.
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http://dx.doi.org/10.1016/j.jss.2020.08.042DOI Listing
February 2021

No difference in mortality between level I and level II trauma centers performing surgical stabilization of rib fracture.

Am J Surg 2021 05 26;221(5):1076-1081. Epub 2020 Sep 26.

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

Background: A comparison of outcomes between Level I (LI) and Level II (LII) Trauma Centers (TCs) performing surgical stabilization of rib fracture (SSRF) has not been well described. We sought to compare risk of mortality for patients undergoing SSRF between LI and LII TCs.

Methods: The Trauma Quality Improvement Program was queried for patients presenting with rib fracture to LI or LII TCs from 2010 to 2015. A multivariable logistic regression analysis was performed.

Results: 14,046 (7.1%) of 199,020 patients with rib fractures underwent SSRF. SSRF increased from 1304 in 2010 to 3489 in 2015: a geometric mean annual increase of 22%. LI TCs demonstrated a mortality incidence of 1.6% while LII TCs demonstrated a mortality incidence of 1.5% (p > 0.05). There was no statistically significant difference in risk of mortality after SSRF between LI and LII TCs (odds ratio 1.12, confidence interval 0.79-1.59, p-value 0.529).

Conclusions: Patients undergoing SSRF at LI and LII TCs have no significant difference in risk of mortality. Additionally, there is an annually growing trend across all centers in SSRF performed both for flail and non-flail segments.
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http://dx.doi.org/10.1016/j.amjsurg.2020.09.033DOI Listing
May 2021

Trauma patients with tibia/fibula fractures are associated with an increased risk of torso, severe head, and severe spine injuries compared to patients with femur fractures.

Injury 2021 Jun 23;52(6):1346-1350. Epub 2020 Sep 23.

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

Background: Although previous studies have demonstrated an association between lower extremity fractures and concomitant torso (thorax and abdomen) injuries in trauma patients, they do not compare different types of fractures. Therefore, we investigated the risk of associated torso injuries between femur and tibia/fibula fractures, hypothesizing that trauma patients with femur fractures are at higher risk of torso injuries compared to patients with tibia/fibula fractures.

Methods: The Trauma Quality Improvement Program database (2010-2016) was queried for patients presenting with either femur or tibia/fibula fractures. Patients with ground-level falls and penetrating injuries were excluded. Univariable and multivariable logistic regression analyses were performed.

Results: From 162,354 patients, 104,075 (64.1%) patients had femur fractures and 58,279 (35.9%) had tibia/fibula fractures. Compared to those with femur fractures, patients with tibia/fibula fractures had a higher incidence of torso injuries (32.2% vs. 17.7%, p<0.001). The tibia/fibula fracture group was also associated with an increased risk of torso (OR 2.22, CI 2.17-2.27, p<0.001), severe (abbreviated injury scale grade > 3) head (OR 2.38, CI 2.30-2.46, p<0.001), and severe spine injuries (OR 2.33, CI 2.07-2.62, p<0.001) compared to the femur fracture group. Additionally, patients with tibia/fibula fractures had a higher rate of deep vein thrombosis (2.5% vs. 1.8%, p<0.001) than patients with femur fractures.

Conclusions: Contrary to previous studies, we demonstrate patients with tibia/fibula fractures have a higher associated risk of torso, severe head and severe spine injuries than patients with femur fractures. Therefore, trauma surgeons should manage tibia/fibula fracture patients with similar clinical vigilance as femur fracture patients.
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http://dx.doi.org/10.1016/j.injury.2020.09.050DOI Listing
June 2021

Comparison of Nonoperative and Operative Management of Traumatic Penetrating Internal Jugular Vein Injury.

Ann Vasc Surg 2021 Apr 16;72:440-444. Epub 2020 Sep 16.

Department of General Surgery, University of California, Irvine Medical Center, Orange, CA. Electronic address:

Background: Small case series have suggested that selective nonoperative management (NOM) of penetrating internal jugular vein (IJV) injuries is safe and feasible in select patients lacking "hard signs" mandating exploration. Therefore, we sought to compare NOM to operative management (OM) of penetrating IJV injury, hypothesizing that both strategies have similar patient outcomes and mortality when patients are appropriately selected.

Methods: The Trauma Quality Improvement Program (2013-2016) was queried for patients with penetrating IJV injury with an abbreviated injury scale score of the neck ≥3. Demographics and patient outcomes were compared between patients undergoing NOM and patients undergoing OM, followed by a multivariable logistic regression model to analyze the risk of mortality.

Results: A penetrating IJV injury was identified in 188 (0.01%) patients meeting inclusion criteria, and OM was performed in 124 (66.0%) patients, whereas 64 (34.0%) patients underwent NOM. Although the OM group had a higher rate of pneumothorax (8.9% vs. 0.0%, P = 0.01), there was no difference in any other concomitant injuries or demographic data (all P > 0.05). The OM group had a higher rate of ventilator days (3 vs. 2 days, P = 0.01) but no other significant differences in morbidity or mortality (P > 0.05). After controlling for covariates, OM was associated with similar risk of mortality compared with NOM of patients with penetrating IJV injury (odds ratio 1.05, confidence interval 0.23-4.83, P = 0.95).

Conclusions: The NOM of penetrating IJV injuries is associated with similar risk of morbidity and mortality compared with OM, suggesting that NOM may be used in appropriately selected patients. Future research is needed to determine the ideal patients suited for NOM and to identify risk factors and outcomes associated with failure of NOM.
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http://dx.doi.org/10.1016/j.avsg.2020.08.149DOI Listing
April 2021

Comparing unbalanced and balanced ratios of blood products in massive transfusion to pediatric trauma patients: effects on mortality and outcomes.

Eur J Trauma Emerg Surg 2020 Aug 14. Epub 2020 Aug 14.

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

Background: The utilization and impact of various ratios of transfusions for pediatric trauma patients (PTPs) receiving a massive transfusion (MT) are unknown. Therefore, we sought to determine the risk for mortality in PTPs receiving an MT of ≥ 6 units of packed red blood cells (PRBC) within 24 h. We compared PRBC: plasma ratio of > 2:1 (Unbalanced Ratios, UR) versus ≤ 2:1 (Balanced Ratios, BR), hypothesizing decreased risk of mortality with BR.

Methods: The Trauma Quality Improvement Program was queried (2014-2016) for PTPs receiving a MT. A multivariable logistic regression model was used to determine risk of mortality.

Results: From 239 PTPs receiving an MT, 98 (41%) received an UR, whereas 141 (59%) received a BR. The median ratios, respectively, were 2.7:1 and 1.2:1. Compared to BR patients, UR patients had no differences in injury severity score (ISS), hypotension on admission, and intensive care unit stay (all p > 0.05). The mortality rates for BR and UR were similar (46.1% vs. 52.0%, p = 0.366). Controlling for age, ISS, and severe head injury, UR demonstrated similar risk of mortality compared to BR (p = 0.276). Additionally, ≥ 4:1 ratio versus ≤ 2:1 showed no difference in associated risk of mortality (p = 0.489).

Conclusion: In contrast to adult studies, this study demonstrated that MT ratios of > 2:1 and even ≥ 4:1 were associated with similar mortality compared to BR for PTPs. These results suggest pediatric MT resuscitation may not require strict BR as has been shown beneficial in adult trauma patients. Future prospective studies are needed to evaluate the optimal ratio for PTP MT resuscitation.

Level Of Evidence: III; Retrospective Care Management Study.
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http://dx.doi.org/10.1007/s00068-020-01461-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426595PMC
August 2020

Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated Diaphragm Injury After Penetrating Trauma.

Am Surg 2020 May;86(5):493-498

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

Background: Isolated diaphragm injury (IDI) occurs in up to 30% of penetrating left thoracoabdominal injuries. Laparoscopic abdominal procedures have demonstrated improved outcome including decreased postoperative pain and length of stay (LOS) compared to open surgery. However, there is a paucity of data on this topic for penetrating IDI. The aim of this study was to examine the prevalence and outcome of laparoscopic diaphragmatic repair versus open diaphragmatic repair (LDR vs ODR) of IDI.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for patients with IDI who underwent ODR versus LDR. A bivariate analysis using Pearson chi-square and Mann-Whitney test was performed to determine LOS among the two groups.

Results: From 2039 diaphragm injuries, 368 patients had IDI; 281 patients (76.4%) underwent ODR and 87 (23.6%) underwent LDR. Compared to LDR, the ODR patients were older (median, 31 vs 25 years, < .001) and had a higher injury severity score (mean, 11.2 vs 9.6, = .03) but had similar rates of intensive care unit LOS, unplanned return to the operating room, ventilator days, and complications ( > .05). Patients undergoing ODR had a longer LOS (5 vs 4 days, = .01), compared to LDR. There were no deaths in either group.

Conclusions: Trauma patients presenting with IDI undergoing ODR had a longer hospital LOS compared to patients undergoing LDR with no difference in complications or mortality. Therefore, we recommend when possible an LDR should be employed to decrease hospital LOS. Further research is needed to examine other benefits of laparoscopy such as postoperative pain, incisional hernia, and wound-related complications.
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http://dx.doi.org/10.1177/0003134820919724DOI Listing
May 2020

Trauma patients with human immunodeficiency virus (HIV): a propensity matched analysis.

Eur J Trauma Emerg Surg 2020 May 24. Epub 2020 May 24.

Division of Trauma, Burns, Surgical Critical Care and Acute Care Surgery, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.

Background: Given the growing number of people worldwide living with human immunodeficiency virus (HIV), a larger subset of these patients are now susceptible to sustaining a traumatic injury. However, the impact of HIV on outcomes in trauma with modern antiretroviral treatment remains unclear. We hypothesized mortality and rates of infectious and inflammatory complications would be higher in HIV positive (HIV+) trauma patients.

Methods: The Trauma Quality Improvement Program was queried to identify trauma patients  ≥ 18 years of age with HIV. Due to the imbalance between HIV+ and HIV negative (HIV-) trauma patients, a 1:2 propensity-matched model was utilized. Matched variables included age, injury severity score, mechanism of injury, systolic blood pressure, pulse rate, Glasgow Coma Scale score, and patient comorbidities.

Results: 84 HIV+ patients were matched to 168 HIV- patients. Compared to HIV- patients, HIV+ patients had no significant differences in mortality rate (9.5% vs. 4.8%, p = 0.144) or infectious complications, including pneumonia (6.0% vs. 4.2%, p = 0.530), urinary tract infection (1.2% vs. 1.2%, p = 1.000), or severe sepsis (1.2% vs. 0.0%, p = 0.156). However, higher rates of acute respiratory distress syndrome (ARDS) (9.5% vs. 0.6%, p < 0.001) and acute kidney injury (AKI) (4.8% vs. 0.0%, p = 0.004) were observed.

Conclusion: HIV+ trauma patients are not at higher risk of mortality or infectious complications, likely due to the advent and prevalence of combination antiretroviral therapy. However, HIV positivity appears to increase the risk of AKI and ARDS in trauma patients. Further research is needed to confirm this finding to elucidate the etiology underlying this association.
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http://dx.doi.org/10.1007/s00068-020-01402-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246034PMC
May 2020

Implementation of a High-Value Care Curriculum for General Surgery Residents.

J Surg Educ 2020 Sep - Oct;77(5):1194-1201. Epub 2020 Mar 31.

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

Introduction: Healthcare expenditures account for more than 3.5 trillion dollars annually with estimates of nearly one-half being wasteful. High-value care (HVC) balances the benefits, harms, and costs of healthcare. Since 2012, the American College of Physicians and Accreditation Council for Graduate Medical Education developed a HVC curriculum and incorporated HVC into milestones for medicine residents. However, currently no HVC curriculum or milestones exist for general surgery residents (GSR). We sought to implement a HVC curriculum for GSR and evaluate awareness and attitudes toward HVC, hypothesizing improved resident awareness and attitudes toward HVC without affecting patient outcomes.

Methods: A prospective comparison between pre-HVC curriculum (7/1/2017-11/30/2017) and post-HVC curriculum (2/1/2018-6/30/2018) was performed. The curriculum included 6 didactic lectures with group discussions. A 14-question Likert-scale survey evaluating awareness, use of, and attitudes toward HVC was performed on all GSR. Additional patient outcomes were collected for all trauma patients cared for during the study period. Bivariate analysis using Mann-Whitney U test was performed.

Results: There were 38/38 GSR respondents (100% response rate) for the pre-HVC survey and 35/38 (92.1% response rate) for the post-HVC survey. More post-HVC respondents somewhat agreed (34.3% vs 5.3%) and less strongly disagreed (31.4% vs 52.6%) with improved knowledge of where to find costs of labs/imaging/treatment (p = 0.02) compared to the pre-HVC group. More post-HVC respondents strongly agreed they balanced the benefit of clinical care with costs and harm when treating patients (25.7% vs 21.1%; p = 0.01). More post-HVC respondents strongly agreed they customized care plans to incorporate patients' values/concerns after implementation of the curriculum (51.4% vs 23.7%, p = 0.0006). From 3254 trauma patients studied, 1722 (52.9%) were pre-HVC and 1532 (47.1%) post-HVC patients. There was no difference between the pre- and post-HVC-curriculum trauma patients in terms of demographics and outcomes such as mortality (3.6% vs 2.4%, p = 0.07) and median length of stay (2 vs 2 days, p = 0.6).

Conclusions: Implementation of a HVC curriculum for GSR led to improved awareness regarding healthcare costs and customizing decision plans for patients, with no difference in trauma patient outcomes. Future research incorporating cost data is needed; however, with implementation of the 2020 general surgery milestones (addition of Systems-Based Practice-3), this curriculum could prove beneficial.
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http://dx.doi.org/10.1016/j.jsurg.2020.03.006DOI Listing
June 2021

The effects of smoking on adolescent trauma patients: a propensity-score-matched analysis.

Pediatr Surg Int 2020 Jun 31;36(6):743-749. Epub 2020 Mar 31.

Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.

Purpose: Cigarettes have been demonstrated to be toxic to the pulmonary connective tissue by impairing the lung's ability to clear debris, resulting in infection and acute respiratory distress syndrome (ARDS). Approximately 8% of adolescents are smokers. We hypothesized that adolescent trauma patients who smoke have a higher rate of ARDS and pneumonia when compared to non-smokers.

Methods: The Trauma Quality Improvement Program (2014-2016) was queried for adolescent trauma patients aged 13-17 years. Adolescent smokers were 1:2 propensity-score-matched to non-smokers based on age, comorbidities, and injury type. Data were analyzed using chi square for categorical data and Mann-Whitney U test for continuous data.

Results: From 32,610 adolescent patients, 997 (3.1%) were smokers. After matching, 459 smokers were compared to 918 non-smokers. There were no differences in matched characteristics. Compared to non-smokers, smokers had an increased rate of pneumonia (3.1% vs. 1.1%, p = 0.01) but not ARDS (0.2% vs. 0%, p = 0.16). Compared to the non-smoking group, the smokers had a longer median total hospital length-of-stay (3 vs. 2 days, p = 0.01) and no difference in overall mortality (1.5% vs. 2.4%, p = 0.29).

Conclusion: Smoking is associated with an increased rate of pneumonia in adolescent trauma patients. Future research should target smoking cessation and/or interventions to mitigate the deleterious effects of smoking in this population.
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http://dx.doi.org/10.1007/s00383-020-04654-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223784PMC
June 2020

Obesity associated with increased postoperative pulmonary complications and mortality after trauma laparotomy.

Eur J Trauma Emerg Surg 2020 Feb 22. Epub 2020 Feb 22.

Division of Trauma, Burns, Surgical Critical Care and Acute Care Surgery, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.

Background: Patient-related risk factors for the development of postoperative pulmonary complications (PPCs) include age ≥ 60-years, congestive heart failure, hypoalbuminemia and smoking. The effect of obesity is unclear and has not been shown to independently increase the likelihood of PPCs in trauma patients undergoing trauma laparotomy. We hypothesized the likelihood of mortality and PPCs would increase as body mass index (BMI) increases in trauma patients undergoing trauma laparotomy.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried to identify trauma patients ≥ 18-years-old undergoing trauma laparotomy within 6-h of presentation. A multivariable logistic regression analysis was used to determine the likelihood of PPCs and mortality when stratified by BMI.

Results: From 8,330 patients, 2,810 (33.7%) were overweight (25-29.9 kg/m), 1444 (17.3%) obese (30-34.9 kg/m), 580 (7.0%) severely obese (35-39.9 kg/m), and 401 (4.8%) morbidly obese (≥ 40 kg/m). After adjusting for covariates including age, injury severity score, chronic obstructive pulmonary disease, smoking, and rib/lung injury, the likelihood of PPCs increased with increasing BMI: overweight (OR = 1.37, CI 1.07-1.74, p = 0.012), obese (OR = 1.44, CI 1.08-1.92, p = 0.014), severely obese (OR = 2.20, CI 1.55-3.14, p < 0.001), morbidly obese (OR = 2.42, CI 1.67-3.51, p < 0.001), compared to those with normal BMI. In addition, the adjusted likelihood of mortality increased for the morbidly obese (OR = 2.60, CI 1.78-3.80, p < 0.001) compared to those with normal BMI.

Conclusion: Obese trauma patients undergoing emergent trauma laparotomy have a high likelihood for both PPCs and mortality, with morbidly obese trauma patients having the highest likelihood for both. This suggests obesity should be accounted for in risk prediction models of trauma patients undergoing laparotomy.
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http://dx.doi.org/10.1007/s00068-020-01329-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222077PMC
February 2020

Outcomes after pneumonectomy versus limited lung resection in adults with traumatic lung injury.

Updates Surg 2020 Jun 21;72(2):547-553. Epub 2020 Feb 21.

Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.

Pneumonectomy after traumatic lung injury (TLI) is associated with shock, increased pulmonary vascular resistance, and eventual right ventricular failure. Historically, trauma pneumonectomy (TP) mortality rates ranged between 53 and 100%. It is unclear if contemporary mortality rates have improved. Therefore, we evaluated outcomes associated with TP and limited lung resections (LLR) (i.e., lobectomy and segmentectomy) and aimed to identify predictors of mortality, hypothesizing that TP is associated with greater mortality versus LLR. We queried the Trauma Quality Improvement Program (2010-2016) and performed a multivariable logistic regression to determine the independent predictors of mortality in TLI patients undergoing TP versus LLR. TLI occurred in 287,276 patients. Of these, 889 required lung resection with 758 (85.3%) undergoing LLR and 131 (14.7%) undergoing TP. Patients undergoing TP had a higher median injury severity score (26.0 vs. 24.5, p = 0.03) but no difference in initial median systolic blood pressure (109 vs. 107 mmHg, p = 0.92) compared to LLR. Mortality was significantly higher for TP compared to LLR (64.9% vs 27.2%, p < 0.001). The strongest independent predictor for mortality was undergoing TP versus LLR (OR 4.89, CI 3.18-7.54, p < 0.001). TP continues to be associated with a higher mortality compared to LLR. Furthermore, TP is independently associated with a fivefold increased risk of mortality compared to LLR. Future investigations should focus on identifying parameters or treatment modalities that improve survivability after TP. We recommend that surgeons reserve TP as a last-resort management given the continued high morbidity and mortality associated with this procedure.
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http://dx.doi.org/10.1007/s13304-020-00727-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223758PMC
June 2020

Intracranial pressure monitoring associated with increased mortality in pediatric brain injuries.

Pediatr Surg Int 2020 Mar 14;36(3):391-398. Epub 2020 Jan 14.

Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA.

Background: Utilization of ICP monitors for pediatric patients is low and varies between centers. We hypothesized that in more severely injured patients (GCS 3-4), there would be a decreased mortality associated with invasive monitoring devices.

Methods: The pediatric Trauma Quality Improvement Program (TQIP) was queried for patients aged ≤ 16 years meeting criteria for invasive monitors. Our primary outcome was mortality. Patients with ICP monitoring were compared to those without. A logistic regression was used to examine the risk of mortality.

Results: Of 3,808 patients, 685 (18.0%) underwent ICP monitoring. ICP monitors were associated with increased risk of mortality (OR 1.82, CI 1.36-2.44, p < 0.001). A secondary analysis including type of invasive ICP monitor and dividing GCS into 3 categories revealed both intraventricular drain (OR 1.89, CI 1.3-2.7, p = 0.001) and intraparenchymal pressure monitor (OR 1.86, CI 1.32-2.6, p < 0.001) to be independently associated with an increased likelihood of mortality regardless of GCS, while intraparenchymal oxygen monitoring was not (OR 0.47, CI 0.11-2.05, p = 0.316). The strongest effect was seen in those patients with a GCS of 5-6.

Conclusion: ICP monitors are an independent risk factor for mortality, particularly with intraventricular drains and intraparenchymal monitors in patients with a GCS 5-6.
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http://dx.doi.org/10.1007/s00383-020-04618-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223517PMC
March 2020

Analysis of blunt cerebrovascular injury in pediatric trauma.

J Trauma Acute Care Surg 2019 12;87(6):1354-1359

From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, (A.G., M.D., M.L., R.M.F., N.-K.K., R.B., J.N.), University of California, Irvine, Orange; and Department of Anesthesia (C.M.K.), University of Southern California, Los Angeles, California.

Background: Blunt cerebrovascular injury (BCVI) occurs in <1% of pediatric patients. The two principal screening criteria for BCVI in children are the Utah and McGovern Score with motor vehicle accident (MVA) considered to be a predictor for BCVI. We sought to confirm previously reported risk factors and identify novel associations with BCVI in pediatric patients.

Methods: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years presenting after blunt trauma. A multivariable logistic regression was used to determine risk of BCVI.

Results: From 69,149 pediatric patients, 109 (<0.2%) had BCVI. The median age was 13 years, and the median Injury Severity Score was 25. More than half the patients were involved in MVAs (53.2%) and had a skull base fracture (53.2%). Factors independently associated with BCVI include skull base fracture (odds ratio [OR], 3.84; 95% confidence interval [CI], 2.40-6.14; p < 0.001), cervical spine fracture (OR, 3.15; 95% CI, 1.91-5.18; p < 0.001), intracranial hemorrhage (OR, 3.11; 95% CI, 1.89-5.14; p < 0.001), Glasgow Coma Scale score of 8 or less (OR, 2.11; 95% CI, 1.33-3.54; p = 0.003), and mandible fracture (OR, 1.99; 95% CI, 1.05-3.84; p = 0.04). Motor vehicle accident was not an independent predictor for BCVI (p = 0.07).

Conclusion: In the largest analysis of pediatric BCVI to date, skull base fracture had the strongest association with BCVI. Other associations to pediatric BCVI included cervical spine and mandible fracture. Motor vehicle accident, previously identified to be associated with BCVI, was not an independent risk factor in our analysis. A future multicenter study incorporating newly identified variables in a scoring system to screen for BCVI is warranted.

Level Of Evidence: Level IV (Prognostic/Epidemiologic).
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http://dx.doi.org/10.1097/TA.0000000000002511DOI Listing
December 2019

Early Tracheostomy for Severe Pediatric Traumatic Brain Injury is Associated with Reduced Intensive Care Unit Length of Stay and Total Ventilator Days.

J Intensive Care Med 2020 Nov 27;35(11):1346-1351. Epub 2019 Aug 27.

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

Objectives: To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy.

Design: Retrospective cohort analysis.

Setting: The Pediatric Trauma Quality Improvement Program (TQIP) database.

Patients: One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016.

Interventions: Not applicable.

Measurements And Main Results: The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups.

Conclusion: Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings.

Article Tweet: Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.
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http://dx.doi.org/10.1177/0885066619870153DOI Listing
November 2020

Increased risk of head injury in pediatric patients with attention deficit hyperactivity disorder.

J Child Adolesc Psychiatr Nurs 2019 11 21;32(4):171-176. Epub 2019 Jul 21.

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

Objective: The prevalence of attention deficit hyperactivity disorder (ADHD) in the general pediatric population is 7%, whereas the prevalence in trauma is unknown. We hypothesized pediatric patients with ADHD would have a higher risk of involvement in a mechanism of injury (MOI) requiring constant attention to surroundings, such as a bicycle collision.

Methods: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients with ADHD. Patients, less than 16 years of age, with ADHD were compared to those without ADHD.

Results: The prevalence of ADHD was 2.5% (2,866). ADHD patients had higher risk for bicycle collision (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.59-2.15; p < .001). ADHD bicyclists were less likely to wear a helmet (9.4% vs. 18.2%, p = .003) and had a higher rate of traumatic brain injury (TBI; 55.6% vs. 39.7%, p < .001), compared to non-ADHD bicyclists.

Conclusions: Pediatric ADHD patients have a 60% higher risk of being involved in a bicycle collision. ADHD patients that are involved in a bicycle collision are less likely to wear a helmet with a higher rate of TBI. Increased public awareness, education, and supervision may help reduce risk of bicycle collisions and TBI in this population.
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http://dx.doi.org/10.1111/jcap.12246DOI Listing
November 2019

Smoking is associated with an improved short-term outcome in patients with rib fractures.

Eur J Trauma Emerg Surg 2020 Aug 18;46(4):927-933. Epub 2019 May 18.

Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.

Background: Smokers with cardiovascular disease have been reported to have decreased mortality compared to non-smokers. Rib fractures are associated with significant underlying injuries such as lung contusions, lacerations, and/or pneumothoraces. We hypothesized that blunt trauma patients with rib fractures who are smokers have decreased ventilator days and risk of in-hospital mortality compared to non-smokers.

Study Design: The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a blunt rib fracture. Patients that died within 24 h of admission were excluded. A multivariable logistic regression model was performed.

Results: From 282,986 patients with rib fractures, 57,619 (20.4%) were smokers. Compared to non-smokers with rib fractures, smokers had a higher median injury severity score (17 vs. 16, p < 0.001). Smokers had a higher rate of pneumonia (7.5% vs. 6.6%, p < 0.001), however, less ventilator days (5 vs. 6, p = 0.04), and lower in-hospital mortality rate (2.3% vs. 4.6%, p < 0.001), compared to non-smokers. After controlling for covariates, smokers with rib fractures were associated with a decreased risk for in-hospital mortality compared to non-smokers with rib fractures (OR 0.64, 0.56-0.73, p < 0.001).

Conclusion: Despite having more severe injuries and increased rates of pneumonia, smokers with rib fractures were associated with nearly a 40% decreased risk of in-hospital mortality and one less ventilator day compared to non-smokers. The long-term detrimental effects of smoking have been widely established. However, the biologic and pathophysiologic adaptations that smokers have may confer a survival benefit when recovering in the hospital from chest wall trauma. This study was limited by the database missing the number of pack-years smoked. Future prospective studies are needed to confirm this association and elucidate the physiologic mechanisms that may explain these findings.
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http://dx.doi.org/10.1007/s00068-019-01152-yDOI Listing
August 2020

Patients with gunshot wounds to the torso differ in risk of mortality depending on treating hospital.

Updates Surg 2019 Sep 22;71(3):561-567. Epub 2019 Apr 22.

Division of Trauma, Burns, Surgical Critical Care, and Acute Care Surgery, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, USA, 92868-3298.

Previous studies have had conflicting results when comparing risk of mortality in patients with gunshot wounds (GSWs) treated at Level-I and II trauma centers. However, the populations studied were restricted geographically. We hypothesized that patients presenting after a GSW to the torso at Level-I centers would have a shorter time to surgical intervention (exploratory laparotomy or thoracotomy) and a lower risk of mortality, compared to Level-IIs in a national database. The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting to Level-I or II trauma center after a GSW to the torso. A multivariable logistic regression analysis was performed. From 17,965 patients with GSWs, 13,812 (76.8%) were treated at Level-Is and 4153 (23.2%) at Level-IIs. There was no difference in the injury severity score (ISS) (p = 0.55). The Level-I cohort had a higher rate of laparotomy (38.9% vs. 36.5%, p < 0.001) with a shorter median time to laparotomy (49 vs. 55 min, p < 0.001) but no difference in rate (p = 0.14) and time to thoracotomy (p = 0.62). After adjusting for covariates, only patients undergoing thoracotomy (OR = 0.66, CI = 0.47-0.95, p = 0.02) or those undergoing non-operative management (NOM) (OR = 0.85, CI = 0.74-0.98, p = 0.03) at a Level-I center had lower risk for death, compared to Level-II. Patients with torso GSWs managed with thoracotomy or NOM at a Level-I center have a lower risk of mortality, compared to a Level-II. Future prospective studies examining variations in practice, resources available and surgeon experience to account for these differences are warranted.
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http://dx.doi.org/10.1007/s13304-019-00657-wDOI Listing
September 2019

Early Versus Late Pulmonary Embolism in Trauma Patients: Not All Pulmonary Embolisms are Created Similarly.

J Surg Res 2019 07 2;239:174-179. Epub 2019 Mar 2.

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

Background: Pulmonary embolism (PE) is an uncommon complication occurring in up to 5% of trauma patients. In small previous studies, patients with long-bone fractures were associated with a higher risk of early PE while those with severe head injuries were at higher risk for late PE.

Materials And Methods: This was a retrospective analysis at a single level I trauma center from 2010 to 2017. Patients with early PE (≤4 d) were compared to those with late PE (>4 d) using bivariate analysis and multivariable logistic regression analysis. We sought to confirm risk factors for early and late PE, hypothesizing that early PE is associated with long-bone fractures and late PE is associated with above-the-knee deep venous thrombosis (DVT).

Results: From 12,833 trauma admissions, 76 patients (0.6%) had a PE. Of these, 33 (43.4%) had an early PE and 43 (54.6%) were diagnosed with late PE. After adjusting for covariates, independent risk factors for late PE included above-the-knee DVT (odds ratio [OR] = 12.01, confidence interval [CI] = 1.34-107.52, P = 0.03), blood transfusion (OR = 8.99, CI = 1.75-46.22, P = 0.009), and craniotomy (OR = 8.82, CI = 1.03-75.97, P = 0.04), while the only independent risk factor for early PE was smoking (OR = 4.56, CI 1.06-19.66, P = 0.04). Severe head injury and long-bone fractures were not risk factors for early or late PE (P > 0.05) CONCLUSIONS: The strongest risk factor for late PE is above-the-knee DVT. Contrary to previous reports, long-bone extremity fractures and severe head injuries are not associated with early or late PE. The only risk factor for early PE was a history of smoking.
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http://dx.doi.org/10.1016/j.jss.2019.02.018DOI Listing
July 2019

Pressure Ulcer in Trauma Patients: A Higher Spinal Cord Injury Level Leads to Higher Risk.

J Am Coll Clin Wound Spec 2017 19;9(1-3):24-31.e1. Epub 2018 Jun 19.

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

Background: In a systematic review, the level of spinal cord injury (SCI) was not associated with risk for pressure ulcer (PU). We hypothesized that in the acute trauma population, upper-SCI (cervical/thoracic) has greater risk for PU when compared to lower-SCI (lumbar/sacral). We additionally sought to identify risk factors for development of PUs in trauma.

Methods: A retrospective analysis of the NTDB (2007-2015) was performed. Covariates were included in a multivariable logistic regression analysis to determine risk for PU.

Results: Of 62,929 patients (0.9%) with SCI, most had an upper-SCI (83%). The overall rate of PUs in patients with SCI was 5.1%. More patients with upper-SCI developed PUs compared to lower-SCI (5.8% vs. 2.2%, p < 0.001). SCI was the strongest predictor for PU (OR = 13.77, CI = 13.25-14.31, p < 0.001). Upper-SCI demonstrated greater risk compared to lower-SCI (OR = 2.81, CI = 2.45-3.22, p < 0.001).

Conclusions: Contrary to previous reports, a higher SCI level is associated with a three-fold greater risk for PU compared to lower SCI.
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http://dx.doi.org/10.1016/j.jccw.2018.06.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304286PMC
June 2018
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