Publications by authors named "Michael Lekawa"

80 Publications

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Discussion: There exists a significant racial disparity in access to neurosurgeon staffing with additional disparities in outcomes based on staffing. Future efforts are needed to improve this chasm of care that exists for trauma patients of color.
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http://dx.doi.org/10.1177/0003134820983187DOI Listing
December 2020

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

Endovascular management of traumatic pseudoaneurysms.

CVIR Endovasc 2020 Nov 27;3(1):88. Epub 2020 Nov 27.

Department of Radiological Sciences, University of California, Irvine, 101 The City Drive South, Rm 115 Rte 140, Orange, CA, 92868, USA.

Background: Pseudoaneurysms (PAs) caused by traumatic injury to the arterial vasculature have a high risk of rupture, leading to life-threatening hemorrhage and mortality, requiring urgent treatment. The purpose of this study was to determine the technical and clinical outcomes of endovascular treatment of visceral and extremity traumatic pseudoaneurysms.

Methods: Clinical data were retrospectively collected from all patients presenting for endovascular treatment of PAs between September 2012 and September 2018 at a single academic level one trauma center. Technical success was defined as successful treatment of the PA with no residual filling on post-embolization angiogram. Clinical success was defined as technical successful treatment with no rebleeding throughout the follow-up period and no reintervention for the PA.

Results: Thirty-five patients (10F/25M), average age (± stdev) 41.7 ± 20.1 years, presented with PAs secondary to blunt (n = 31) or penetrating (n = 4) trauma. Time from trauma to intervention ranged from 2 h - 75 days (median: 4.4 h, IQR: 3.5-17.1 h) with 27 (77%) of PAs identified and treated within 24 h of trauma. Average hospitalization was 13.78 ± 13.4 days. Ten patients underwent surgery prior to intervention. PA number per patient ranged from 1 to 5 (multiple diffuse). PAs were located on the splenic (n = 12, 34.3%), pelvic (n = 11, 31.4%), hepatic (n = 9, 25.7%), upper extremity/axilla (n = 2, 5.7%), and renal arteries (n = 1, 2.9%). Technical success was 85.7%. Clinical success was 71.4%, for technical failure (n = 5), repeat embolization (n = 1) or post-IR surgical intervention (n = 4). There was no PA rebleeding or reintervention for any patient after discharge over the reported follow-up periods. Three patients died during the trauma hospitalization for reasons unrelated to the PAs.

Conclusions: Endovascular treatment of traumatic visceral and extremity PAs is efficacious with minimal complication rates and low reintervention requirements.
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http://dx.doi.org/10.1186/s42155-020-00182-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695774PMC
November 2020

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

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

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

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

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

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

Discussion: Coronavirus disease 2019-related stressors may have triggered an increase in firearm purchases nationally and within NYS in March 2020. Firearm incidents also increased in NYS. SIP orders had no effect on firearm purchases and firearm violence.
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http://dx.doi.org/10.1177/0003134820954827DOI Listing
May 2021

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

Am Surg 2021 Jun 24;87(6):864-871. Epub 2020 Nov 24.

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

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

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

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

Conclusion: Preoperative chemotherapy/radiation does not contribute to risk for ALs after esophagectomy. There is a stepwise increased risk of 30-day mortality for ALs requiring increased invasiveness of treatment.
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http://dx.doi.org/10.1177/0003134820956329DOI Listing
June 2021

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

Am Surg 2021 Jun 24;87(6):864-871. Epub 2020 Nov 24.

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

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

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

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

Conclusion: Preoperative chemotherapy/radiation does not contribute to risk for ALs after esophagectomy. There is a stepwise increased risk of 30-day mortality for ALs requiring increased invasiveness of treatment.
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http://dx.doi.org/10.1177/0003134820956329DOI Listing
June 2021

Helmets Protect Pediatric Bicyclists From Head Injury and Do Not Increase Risk of Cervical Spine Injury.

Pediatr Emerg Care 2020 Nov 11. Epub 2020 Nov 11.

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

Objectives: Only 21 states have mandatory helmet laws for pediatric bicyclists. This study sought to determine the incidence of helmeted riders among pediatric bicyclists involved in a collision and hypothesized the risk of a serious head and cervical spine injuries to be higher in nonhelmeted bicyclists (NHBs) compared with helmeted bicyclists (HBs).

Methods: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for pediatric (age <16 years) bicyclists involved in a collision. Helmeted bicyclists were compared with NHBs. A serious injury was defined by an abbreviated injury scale grade of greater than 2.

Results: From 3693 bicyclists, 3039 (82.3%) were NHBs. Compared with HBs, NHBs were more often Black (21.6% vs 3.8%, P < 0.001), Hispanic (17.5% vs 9.3%, P < 0.001), without insurance (4.6% vs 2.4%, P = 0.012), and had a higher rate of a serious head injury (24.6% vs 9.3%, P < 0.001). Both groups had similar rates of complications and mortality (P > 0.05). The associated risk of a serious head (odds ratio = 3.17, P < 0.001) and spine injury (odds ratio = 0.41, P = 0.012) were higher and lower respectively in NHBs. Associated risks for cervical spine fracture or cord injury were similar (P > 0.05).

Conclusions: Pediatric bicyclists involved in a collision infrequently wear helmets, and NHBs was associated with higher risks of serious head injury. However, the associated risk of serious spine injury among NHBs was lower. The associated risks for cervical spine fracture or cervical cord injuries were similar. Nonhelmeted bicyclists were more likely to lack insurance and to be Black or Hispanic. Targeted outreach programs may help decrease the risk of injury, especially in at-risk demographics.
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http://dx.doi.org/10.1097/PEC.0000000000002290DOI Listing
November 2020

Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures.

Am Surg 2021 May 10;87(5):747-752. Epub 2020 Nov 10.

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

Background: A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed.

Results: From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, = .029) and BPI (18.2% vs. .4%, < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, < .001).

Conclusion: The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.
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http://dx.doi.org/10.1177/0003134820952832DOI Listing
May 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

Association of Risk of Mortality in Pediatric Patients Transferred From Scene by Helicopter With Major But Not Minor Injuries.

Pediatr Emerg Care 2020 Oct 22. Epub 2020 Oct 22.

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

Objectives: Helicopter emergency medical services (HEMS) are used for 16% of pediatric trauma. National HEMS guidelines advised that triage criteria be standardized for pediatric patients. A national report found pediatric HEMS associated with decreased mortality compared with ground emergency medical services (GEMS) but did not control for transport time. We hypothesized that the rate of HEMS has decreased nationally and the mortality risk for HEMS to be similar when adjusting for transport time compared with GEMS.

Methods: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years transported by HEMS or GEMS. A multivariable logistic regression was used.

Results: From 25,647 patients, 4527 (17.7%) underwent HEMS. The rate of HEMS from scene decreased from 21.2% in 2014 to 18.2% in 2016. The rate of HEMS for minor trauma (Injury Severity Score <15) decreased from 14.9% in 2014 to 13.5% in 2016 and major trauma (Injury Severity Score > 15) from 38.4% in 2014 to 35.9% in 2016. After controlling for predictors of mortality and transport time, HEMS was associated with decreased risk of mortality for only those with major injuries transferred from scene (odds ratio, 0.48; 95% confidence interval, 0.26-0.88; P = 0.01) compared with GEMS.

Conclusions: The rate of HEMS in pediatric trauma has decreased. However, there is room for improvement as 14% of those with minor trauma are transported by HEMS. Given the similar risk of mortality compared with GEMS, further development of guidelines that avoid the unnecessary use of HEMS appears warranted. However, utilization of HEMS for transport of pediatric major trauma should continue.
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http://dx.doi.org/10.1097/PEC.0000000000002263DOI Listing
October 2020

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

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

Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time.

Ann Vasc Surg 2021 Feb 2;71:428-436. Epub 2020 Sep 2.

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

Background: Continued advances in endovascular technologies are resulting in fewer open abdominal aortic aneurysm (AAA) repairs. In addition, more complex juxtarenal, pararenal, and suprarenal (JPS) AAAs are being managed with various endovascular techniques. This study sought to evaluate the evolving trends in endovascular aneurysm repair (EVAR) of AAAs, hypothesizing increased rate of JPS AAA repair by EVAR. We also sought to evaluate the risk for morbidity and mortality for EVAR and open aneurysm repair (OAR) of JPS AAAs over time.

Methods: The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for patients undergoing OAR or EVAR for AAAs. A multivariable logistic regression analysis was performed for both infrarenal and JPS AAA repairs.

Results: Of 18,661 patients who underwent AAA repair, 3,941 (21.1%) were OAR and 14,720 (78.9%) were EVAR. The rate of OAR decreased from 29.5% in 2011 to 21.3% in 2017 (P < 0.001) with a geometric-mean-annual decrease of 27.8%. The rate of EVAR increased from 70.5% to 78.7% during the same time period (P < 0.001) with a geometric-mean-annual increase of 11.6%. These trends remained true for both infrarenal and JPS AAAs. After adjusting for covariates, there was no difference in associated risk of 30-day mortality, renal complications, or ischemic colitis for either OAR or EVAR over each incremental year for infrarenal AAAs (P > 0.05). However, in patients undergoing EVAR for JPS AAAs, the associated risk of mortality increased with each incremental year (odds ratio [OR]: 1.30, confidence interval [CI]: 1.01-1.69, P = 0.039), whereas there was no difference in the risk of mortality for OAR of JPS AAAs with each incremental year (OR: 1.11, CI: 0.99-1.23, P = 0.067).

Conclusions: The rate of OAR for AAA has decreased over the past seven years with an increase in EVAR, particularly for more complex JPS AAAs. The associated risk for morbidity and mortality for treatment of infrarenal AAAs was not significantly affected by this increased utility of EVAR. The associated risk of mortality for JPS AAAs treated by EVAR increased over time, whereas this trend for associated risk of mortality was not seen for OAR of JPS AAAs. These findings, especially the increased associated risk of mortality over time with EVAR for JPS AAAs, warrant careful prospective analysis.
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http://dx.doi.org/10.1016/j.avsg.2020.08.103DOI Listing
February 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

Penetrating Abdominal Aortic Injury: Comparison of ACS-Verified Level-I and II Trauma Centers.

Vasc Endovascular Surg 2020 Nov 13;54(8):692-696. Epub 2020 Aug 13.

Department of Surgery, 8788University of California, Irvine School of Medicine, CA, USA.

Objectives: Penetrating abdominal aortic injury (PAAI) is a highly acute injury requiring prompt surgical management. When compared to surgeons at level-II trauma centers, surgeons at level-I trauma centers are more likely to take in-house call, and may more often be available within 15 minutes of patient arrival. Thus, we hypothesized that level-I trauma centers would have a lower mortality rate than level-II trauma centers in patients with PAAI.

Methods: We queried the Trauma Quality Improvement Program database for patients with PAAI, and compared patients treated at American College of Surgeons (ACS)-verified level-I centers to those treated at ACS level-II centers.

Results: PAAI was identified in 292 patients treated at level-I centers and 86 patients treated at level-II centers. Patients treated at the 2 center types had similar median age, injury severity scores and prevalence of diabetes, hypertension, and smoking (p > 0.05). There was no difference in the frequency of additional intra-abdominal vascular injuries (p > 0.05). Median time to hemorrhage control (level-I: 40.8 vs level-II: 49.2 minutes, p = 0.21) was similar between hospitals at the 2 trauma center levels. We found no difference in the total hospital length of stay or post-operative complications (p > 0.05). When controlling for covariates, we found no difference in the risk of mortality between ACS verified level-I and level-II trauma centers (OR:1.01, CI:0.28-2.64, p = 0.99).

Conclusion: Though the majority of PAAIs are treated at level-I trauma centers, we found no difference in the time to hemorrhage control, or the risk of mortality in those treated at level-I centers when compared to those treated at level-II trauma centers. This finding reinforces the ACS-verification process, which strives to achieve similar outcomes between level-I and level-II centers.
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http://dx.doi.org/10.1177/1538574420947234DOI Listing
November 2020

Analysis of Endovascular Aneurysm Repair for Small Abdominal Aortic Aneurysms in Males.

J Surg Res 2020 12 21;256:163-170. Epub 2020 Jul 21.

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

Background: Current guidelines recommend repair of abdominal aortic aneurysms (AAAs) when ≥5.5 cm. This study sought to evaluate the incidence of male patients undergoing endovascular aneurysm repair (EVAR) for AAAs of various diameters (small <4 cm; intermediate 4-5.4 cm; standard ≥5.5 cm). We analyzed predictors of mortality, hypothesizing that smaller AAAs (<5.5 cm) have no differences in associated risk of mortality compared to standard AAAs (≥5.5 cm).

Methods: The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for male patients undergoing elective EVAR. Patients were stratified by aneurysm diameter. A multivariable logistic regression analysis for clinical outcomes, adjusting for age, clinical characteristics, and comorbidities, was performed.

Results: A total of 8037 male patients underwent EVAR with 3926 (48.9%) performed for AAAs <5.5 cm. There was no difference in mortality, readmission, major complications, myocardial infarction, stroke, or ischemic complications among the 3 groups (P > 0.05). In AAAs <5.5 cm, predictors of mortality included prior abdominal surgery (odds ratio [OR], 5.77; confidence interval [CI], 1.38-24.13; P = 0.016), weight loss (OR, 43.4; CI, 3.78-498.7; P = 0.002), disseminated cancer (OR, 17.9; CI, 1.30-245.97; P = 0.031), and diabetes (OR, 6.09; CI, 1.52-24.36; P = 0.011).

Conclusions: Nearly 50% of male patients undergoing elective EVAR were treated for AAAs <5.5 cm. There was no difference in associated risk of mortality for smaller AAAs compared to standard AAAs. The strongest predictors of mortality for patients with smaller AAAs were prior abdominal surgery, weight loss, disseminated cancer, and diabetes.
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http://dx.doi.org/10.1016/j.jss.2020.06.030DOI Listing
December 2020

Helicopter Transport Has Decreased Over Time and Transport From Scene or Hospital Matters.

Air Med J 2020 Jul - Aug;39(4):283-290. Epub 2020 Apr 20.

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

Objective: Several reports have found helicopter emergency medical services (HEMS) to be associated with a lower risk of mortality compared with ground emergency medical services (GEMS); however, most studies did not control for transport time or stratify interfacility versus scene. We hypothesize that the HEMS transport rate has decreased nationally and that the risk of mortality for HEMS is similar to GEMS when adjusting for transport time and stratifying by scene or interfacility.

Methods: The Trauma Quality Improvement Program (2010-2016) was queried for adult patients transported by HEMS or GEMS. Multivariable logistic regression was used.

Results: The HEMS transport rate decreased by 38.2% from 2010 to 2016 (P < .001). After controlling for known predictors of mortality and transport time, HEMS was associated with a decreased risk of mortality compared with GEMS for adult trauma patient transports (odds ratio = 0.74; 95% confidence interval [CI], 0.71-0.77; P < .001). Compared with GEMS, HEMS transports from the scene were associated with a decreased risk of mortality (OR = 0.63; 95% CI, 0.60-0.66; P < .001), whereas HEMS interfacility transfer was associated with an increased risk of mortality (OR = 1.22; 95% CI, 1.14-1.31; P < .001).

Conclusion: The rate of HEMS transports in trauma has decreased by nearly 40% over the past 7 years. Our results suggest that HEMS use for scene transports is beneficial for the survival of trauma patients.
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http://dx.doi.org/10.1016/j.amj.2020.04.006DOI Listing
June 2021

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

Non-Accidental Trauma Associated with Withdrawal of Life-Sustaining Medical Treatment in Severe Pediatric Traumatic Brain Injury.

J Clin Ethics 2020 ;31(2):111-125

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

Introduction: In highly developed countries, as many as 16 percent of children are physically abused each year. Traumatic brain injury (TBI) is the most common injury in non-accidental trauma (NAT) and is responsible for 80 percent of fatal NAT cases, with most deaths occurring in children younger than three years old. Cases of abusers who refuse withdrawal of life-sustaining medical treatment (LSMT) to avoid criminal charges have previously been reported. Therefore, we hypothesized that NAT is associated with a lower risk for withdrawal LSMT in pediatric TBI.

Methods: The pediatric Trauma Quality Improvement Program database was analyzed (2014 to 2016) for patients aged 16 and younger with TBI and Glasgow Coma Scale (GCS) of 8 and lower on admission. Patients with a head Abbreviated Injury Scale (AIS) of 2 or less or who died within 48 hours were excluded. A multivariable logistic regression model was used for analysis.

Results: Of 2,209 TBI patients, 92 (4.2 percent) had withdrawal of LSMT. Compared to those without withdrawal of LMST, those with LMST had statistically similar median age (three years of age versus seven years) and a higher rate of NAT (33.7 percent versus 13.5 percent). The most common specified perpetrator was a father/stepfather/male partner (70 percent). After adjusting for covariates, factors associated with higher risk for withdrawal of LSMT included age of less than three years (OR 2.38, CI 1.34-4.23) and NAT (OR 1.86, CI 1.02-3.41).

Conclusion: NAT is associated with increased risk for withdrawal of LSMT in pediatric TBI. Age of less than three years is similarly associated with a higher risk for withdrawal of LSMT. Future research in this population is needed to determine what other factors predict withdrawal of LSMT and what resources, such as social workers and/or ethics consults, are utilized.
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September 2020

Geriatric patients undergoing appendectomy have increased risk of intraoperative perforation and/or abscess.

Surgery 2020 Aug 24;168(2):322-327. Epub 2020 May 24.

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

Background: The number of geriatric patients is expected to grow 3-fold over the next 30 years, and as many as 50% of the surgeries done in the United States may occur in geriatric patients. Geriatric patients often have increased comorbidities and more often present in a delayed manner for acute appendicitis. The aim of this study was to evaluate outcomes between geriatric patients and younger patients undergoing appendectomy, hypothesizing that geriatric patients will have a higher risk of abscess and/or perforation, conversion to open surgery, postoperative intra-abdominal abscess, and 30-day readmission.

Methods: The 2016 to 2017 American College of Surgeons National Surgical Quality Improvement Program Procedure Targeted Appendectomy database was queried for patients with preoperative image findings consistent with acute appendicitis. Geriatric patients (age ≥65 years old) were compared with younger patients (age <65 years old). A multivariable logistic regression model was used for analysis.

Results: From 21,586 patients undergoing appendectomy, 2,060 (9.5%) were geriatric patients. Compared with the younger cohort, geriatric patients were less likely to have leukocytosis (59.0% vs 65.8%, P < .001) and more likely to have a tumor and/or malignancy involving the appendix on final pathology (2.0% vs 0.8%, P < .001), an unplanned laparoscopic conversion to open surgery (4.2% vs 1.5%, P < .001), and 30-day readmission (7.0% vs 3.3%, P < .001). Geriatric patients had a longer median length of stay (2 vs 1 days, P < .001) and higher mortality rate (0.5% vs <0.1%, P < .001). After adjusting for covariates, there was an increased associated risk of intraoperative abscess and/or perforation (odds ratio 2.23, 2.01-2.48, P < .001) and postoperative intra-abdominal abscess (odds ratio 1.43, 1.12-1.83, P = .005) but no difference in associated risk for mortality (odds ratio 2.56, 0.79-8.25, P = .116), compared with the younger cohort.

Conclusion: Nearly 10% of laparoscopic appendectomies are done on geriatric patients with geriatric patients having a higher rate of conversion to open surgery and tumor and/or malignancy on final pathology. Geriatric patients have an associated increased risk of intraoperative perforation and/or abscess and postoperative intra-abdominal abscess but have similar risk for mortality compared with nongeriatric patients undergoing laparoscopic appendectomy.
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http://dx.doi.org/10.1016/j.surg.2020.04.019DOI Listing
August 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
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