Publications by authors named "Ronald M Stewart"

100 Publications

A Public Health Approach to Prevent Firearm Related Injuries and Deaths.

Ann Surg 2021 10;274(4):533-543

Department of Surgery, University of Texas Health Science Center, San Antonio, Texas.

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http://dx.doi.org/10.1097/SLA.0000000000005056DOI Listing
October 2021

Firearm Storage Practices of US Members of the American College of Surgeons.

J Am Coll Surg 2021 Sep 22;233(3):331-336. Epub 2021 Jul 22.

American College of Surgeons Committee on Trauma, Chicago, IL; University of Texas San Antonio, Department of Surgery, San Antonio, TX.

Background: As a part of its firearm injury prevention action plan, the American College of Surgeons (ACS) surveyed the entire US ACS membership regarding individual members' knowledge, experience, attitudes, degree of support for ACS Committee on Trauma (COT) firearm programs, and degree of support for a range of firearm injury prevention policies. This survey included questions regarding members' prevalence of firearm ownership, type of firearm(s) owned, type of firearm(s) in the home, personal reasons for firearm ownership, and methods of firearm/ammunition storage.

Study Design: An email invitation to participate in an anonymous, 23-item survey on firearms was sent to all US ACS members (n = 54,761) by a contracted survey research firm. Cross tabulation of questionnaire items by demographic characteristics and chi-square analyses were performed with statistical significance p < 0.05.

Results: The overall response rate was 20.4% (11,147/54,761). Forty-two percent of respondents keep firearms in their home (82% long guns, 82% handguns; 32% high-capacity magazine fed, semi-automatic rifles); 75% keep guns for self-defense/protection, 73% for target shooting; 39% store firearms unlocked, and 32% store guns unlocked and loaded. Results vary by practice/training location, practice type, military experience, sex, age, presence of children in the home, level of training, and race/ethnicity.

Conclusions: A significant percentage of ACS members keep firearms in their home, and nearly one-third store firearms in an unlocked and loaded fashion. Safe storage is a basic tenet of responsible firearm ownership. These data present opportunities for engaging surgeons in efforts to improve safe firearm storage.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.05.024DOI Listing
September 2021

Survey of American College of Surgeons Members on Firearm Injury Prevention.

J Am Coll Surg 2021 Sep 22;233(3):369-382. Epub 2021 Jul 22.

American College of Surgeons Committee on Trauma, Chicago, IL; Department of Surgery, University of Texas San Antonio, San Antonio, TX.

Background: Firearm-related injuries and deaths continue to be a substantial public health burden in the US. The purpose of this study was to describe the results of a survey of US members of the American College of Surgeons (ACS) on their practices, attitudes, and beliefs about firearms and firearm policies. The survey was designed to gain a representative understanding of the views of all US ACS members to help inform ACS positions related to firearm injury prevention.

Study Design: A professional survey firm was engaged to facilitate the design of the survey and to support a web-based platform. Data collection through an anonymous survey began in July 2018, with the survey closing in September 2018. Survey data were weighted and analyses included descriptive and bivariate statistics.

Results: There were 54,761 ACS members invited to participate in the survey. Of those, 11,147 respondents completed the survey, for an overall response rate of 20.4%. Respondents were questioned on firearm experience, purpose of firearm ownership, opinions on firearm ownership, and importance of ACS support for specific firearm legislation. Survey results varied by practice and training location, practice type, military experience, gender, age, presence of children in the home, level of training, and race and ethnicity. Most survey respondents were ACS fellows (n = 7,579 [68%]), male (n = 8,671 [77.8%]), and White (n = 8,639 [77.5%]). Forty-two percent of respondents keep guns in their home. Seventy-five percent of respondents believe that it is very or extremely important for the ACS to support policy initiatives to lower the incidence of firearm injury.

Conclusions: There is broad support among ACS members for many initiatives related to firearm injury prevention. The degree of support for these measures varies based on both the specific initiative and demographic characteristics. The results align with the ACS strategy of healthcare professionals working together to better understand and address the root causes of violence, and simultaneously working together to make firearm ownership as safe as reasonably possible.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.06.020DOI Listing
September 2021

Prehospital whole blood reduces early mortality in patients with hemorrhagic shock.

Transfusion 2021 07;61 Suppl 1:S15-S21

Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA.

Background: Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion.

Study Design And Methods: A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed.

Results: A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05).

Discussion: This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.
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http://dx.doi.org/10.1111/trf.16528DOI Listing
July 2021

Prehospital shock index and systolic blood pressure are highly specific for pediatric massive transfusion.

J Trauma Acute Care Surg 2021 May 10. Epub 2021 May 10.

University of Texas Health Science Center, Department of Trauma and Emergency Surgery, San Antonio, TX 78229-3900 Trauma Surgery, Naval Medical Center Camp Lejeune, Camp Lejeune, NC 28547 University Hospital in San Antonio, Trauma Services, San Antonio, TX 78229-3900 University of Texas Health Science Center, Department of Pathology, San Antonio, TX 78229-3900 Southwest Texas Regional Advisory Council, San Antonio, TX, 78227 University of Texas Health Science Center, Department of Emergency Health Sciences, San Antonio, TX 78229-3900.

Background: While massive transfusion protocols (MTP) are associated with decreased mortality in adult trauma patients, there is limited research on the impact of MTP on pediatric trauma patients. The purpose of this study was to compare pediatric trauma patients requiring massive transfusion to all other pediatric trauma patients to identify triggers for MTP activation in injured children.

Methods: Using our level I trauma center's registry, we retrospectively identified all pediatric trauma patients from January 2015 to January 2018. Massive transfusion (MT) was defined as infusion of 40 mL/kg of blood products in the first 24 hours of admission. Patients missing prehospital vital sign data were excluded from the study. We retrospectively collected data including: demographics, blood utilization, variable outcome data, prehospital vital signs, prehospital transport times, and injury severity scores (ISS). Statistical significance was determined using Mann-Whitney U test and chi-square test. P values less than 0.05 were considered significant.

Results: Thirty-nine of the 2,035 pediatric patients (1.9%) met criteria for MT. All-cause mortality in MT patients was 49% (19/39) versus 0.01% (20/1996) in Non-MT patients. The two groups significantly differed in ISS, prehospital vital signs, and outcome data.Both systolic blood pressure (SBP) <100 mmHg and shock index (SI) >1.4 were found to be highly specific for massive transfusion with specificities of 86% and 92%, respectively. The combination of SBP<100 mmHg and SI>1.4 had a specificity of 94%. The positive and negative predictive values of SBP<100 mmHg and SI >1.4 in predicting massive transfusion were 18% and 98%, respectively. Based on positive likelihood ratios, patients with both SBP<100 mmHg and SI>1.4 were 7.2 times more likely to require massive transfusion than patients who did not meet both of these vital sign criteria.

Conclusions: Pediatric trauma patients requiring early blood transfusion present with lower blood pressures and higher heart rates, as well as higher shock indexes and lower pulse pressures. We found that shock index and systolic blood pressure are highly specific tools with promising likelihood ratios that could be used to identify patients requiring early transfusion.

Levels Of Evidence And Study Type: Therapeutic/Care Management, Level V.
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http://dx.doi.org/10.1097/TA.0000000000003275DOI Listing
May 2021

Invited Commentary on "Pediatric Firearm Injuries and Fatalities: Do Racial Disparities Exist?"

Authors:
Ronald M Stewart

Ann Surg 2020 10;272(4):562-563

The Department of Surgery, UT Health San Antonio and University Hospital, San Antonio, Texas.

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http://dx.doi.org/10.1097/SLA.0000000000004389DOI Listing
October 2020

Domestic Violence and Safe Storage of Firearms in the COVID-19 Era.

Ann Surg 2020 08;272(2):e55-e57

Department of Surgery, Division of Trauma and Burn, and Critical Care Surgery, University of Washington Medicine, Seattle, Washington.

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http://dx.doi.org/10.1097/SLA.0000000000004088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7268852PMC
August 2020

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

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

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

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

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

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

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

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

From battlefront to homefront: creation of a civilian walking blood bank.

Transfusion 2020 06 1;60 Suppl 3:S167-S172. Epub 2020 Jun 1.

Department of Surgery, UT Health San Antonio, San Antonio, Texas.

Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.
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http://dx.doi.org/10.1111/trf.15694DOI Listing
June 2020

Prevention of firearm injuries: It all begins with a conversation.

J Trauma Acute Care Surg 2020 02;88(2):e77-e81

From the University of Nevada Las Vegas School of Medicie, Department of Surgery, (D.A.K.), Las Vegas, Nevada; Cincinnati Children's Hospital Medical Center, Department of Surgery, (R.F.), Cincinnati, Ohio; New Jersey Medical School/Rutgers University, Department of Surgery, (S.B.), Newark, New Jersey; University of Washington, Department of Surgery, (E.M.B.), Seattle, Washington; Connecticut Children's Hospital, Department of Surgery, (B.C.), Hartford, Connecticut; Harvard Medical School/Brigham and Women's Hospital, Department of Surgery, (Z.C.), Boston, Massachusetts; University of California Los Angeles, Department of Surgery, (R.A.D.), Los Angeles, California; Ventura County Medical Center, Department of Surgery, (T.K.D.), Ventura, California; Mission Regional Medical Center, Department of Surgery, (E.J.K.), Orange County, California; Emory University School of Medicine, Department of Psychiatry and Behavioral Health, (D.A.L.), Atlanta, Georgia; Nemours Children's Specialty Care, Department of Surgery, (R.W.L.), Jacksonville, Florida; Harvard Medical School/Massachusetts General Hospital, Department of Surgery, (P.T.M.), Boston, Massachusetts; University of Texas Health Science University, Department of Surgery, (R.M.S.), San Antonio, Texas; and University of California San Francisco, Department of Surgery, (M.M.K.), San Francisco, California.

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http://dx.doi.org/10.1097/TA.0000000000002452DOI Listing
February 2020

The gut microbiome distinguishes mortality in trauma patients upon admission to the emergency department.

J Trauma Acute Care Surg 2020 05;88(5):579-587

From the Division of Trauma and Emergency Surgery, Department of Surgery (D.M.B., T.R.J., S.S., M.D., R.B.J., C.Z., E.S., R.M.S., M.G.S., D.H.J., B.J.E., S.E.N.), Greehey Children's Cancer Research Institute (Z.L.), and Department of Molecular Medicine (Z.L.), UT Health San Antonio, San Antonio, Texas; Department of Medicine, Uniformed Services University of the Health Sciences (D.M.B), Bethesda, MD and US Army Institute of Surgical Research (D.M.B., S.E.N.), Fort Sam Houston, Texas.

Background: Traumatic injury can lead to a compromised intestinal epithelial barrier, decreased gut perfusion, and inflammation. While recent studies indicate that the gut microbiome (GM) is altered early following traumatic injury, the impact of GM changes on clinical outcomes remains unknown. Our objective of this follow-up study was to determine if the GM is associated with clinical outcomes in critically injured patients.

Methods: We conducted a prospective, observational study in adult patients (N = 67) sustaining severe injury admitted to a level I trauma center. Fecal specimens were collected on admission to the emergency department, and microbial DNA from all samples was analyzed using the Quantitative Insights Into Microbial Ecology pipeline and compared against the Greengenes database. α-Diversity and β-diversity were estimated using the observed species metrics and analyzed with t tests and permutational analysis of variance for overall significance, with post hoc pairwise analyses.

Results: Our patient population consisted of 63% males with a mean age of 44 years. Seventy-eight percent of the patients suffered blunt trauma with 22% undergoing penetrating injuries. The mean body mass index was 26.9 kg/m. Significant differences in admission β-diversity were noted by hospital length of stay, intensive care unit hospital length of stay, number of days on the ventilator, infections, and acute respiratory distress syndrome (p < 0.05). β-Diversity on admission differed in patients who died compared with patients who lived (mean time to death, 8 days). There were also significantly less operational taxonomic units in samples from patients who died versus those who survived. A number of species were enriched in the GM of injured patients who died, which included some traditionally probiotic species such as Akkermansia muciniphilia, Oxalobacter formigenes, and Eubacterium biforme (p < 0.05).

Conclusion: Gut microbiome diversity on admission in severely injured patients is predictive of a variety of clinically important outcomes. While our study does not address causality, the GM of trauma patients may provide valuable diagnostic and therapeutic targets for the care of injured patients.

Level Of Evidence: Prognostic and epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002612DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905995PMC
May 2020

A Multicenter Evaluation of a Firearm Safety Intervention in the Pediatric Outpatient Setting.

J Pediatr Surg 2020 Jan 25;55(1):140-145. Epub 2019 Oct 25.

University of Texas Health Sciences Center, San Antonio, TX, USA.

Purpose: Firearm injuries continue to be a common cause of injury for American children. This pilot study was developed to evaluate the feasibility of providing guidance about firearm safety to the parents of pediatric patients using a tablet-based module in the outpatient setting.

Methods: A tablet-based questionnaire that included a firearm safety message based on current best practice was administered to parents of pediatric patients at nine centers in 2018. Parents were shown a firearm safety video and then asked a series of questions related to firearm safety.

Results: The study was completed by 543 parents from 15 states. More than one-third (37%) of families kept guns in their home. The majority of parents (81%, n = 438) thought it was appropriate for physicians to provide firearm safety counseling. Two-thirds (63%) of gun owning parents who do not keep their guns locked said that the information provided in the module would change the way they stored firearms at home.

Conclusion: Use of a tablet based firearm safety module in the outpatient setting is feasible, and the majority of parents are receptive to receiving anticipatory guidance on firearm safety. Further data is needed to evaluate whether the intervention will improve firearm safety practices in the home.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.044DOI Listing
January 2020

Bleeding Control Training for the Lay Public: Keep It Simple.

JAMA Surg 2020 02;155(2):175-176

Division of Trauma, Department of Surgery, University of Texas Health Sciences Center at San Antonio.

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http://dx.doi.org/10.1001/jamasurg.2019.4700DOI Listing
February 2020

Surgery Program Director Turnover Correlates With Residency Graduate Failure on American Board of Surgery Examinations in Civilian Residency Programs.

J Surg Educ 2019 Nov - Dec;76(6):e24-e29. Epub 2019 Oct 9.

Surgical Accreditation, Accreditation Council for Graduate Medical Education, Chicago, Illinois.

Purpose: The Review Committee for Surgery requires a minimum program director (PD) tenure of 6 years. The impact of PD turnover on the performance of program graduates is unknown. We hypothesize that (1) the majority of PDs step down before 6-year tenure and (2) higher PD turnover is associated with higher failure rate on American Board of Surgery (ABS) examinations.

Methods: Start and stop dates of all surgery PDs between January 1, 2000 and December 31, 2017 were obtained for civilian surgery programs. A Kaplan-Meier curve of PD "survival" was constructed. Programs were divided into High Turnover (HT; ≥4 PD changes, n = 33) and Low Turnover (LT; ≤3 PD changes, n = 191) groups. Five-year (2013-2017) ABS pass rates were also obtained. Pass rates and compliance with current standards were compared between groups.

Results: Kaplan-Meier analysis revealed that 40% of PDs do not comply with ACGME policy and serve <6 years. HT programs had lower mean pass rates on ABS certifying exam than LT programs (76% vs 83%, p < 0.01), but not qualifying exam (88% vs 88%). HT programs are less likely to meet the current 65% pass rate standard (82% vs 93%, p < 0.05).

Conclusions: (1) An estimated 40% of general surgery PDs had tenures of <6 years. (2) Greater PD turnover is associated with lower ABS pass rates among general surgery graduates.
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http://dx.doi.org/10.1016/j.jsurg.2019.08.003DOI Listing
December 2020

American Association for the Surgery of Trauma Prevention Committee topical update: Impact of community violence exposure, intimate partner violence, hospital-based violence intervention, building community coalitions and injury prevention program evaluation.

J Trauma Acute Care Surg 2019 Aug;87(2):456-462

From the Division of General Surgery, Lahey Hospital and Medical Center (M.S.R.), Burlington, Massachusetts; Department of Trauma and Burns, John H. Stroger Hospital of Cook County (K.T.J.), Chicago, Illinois; Department of Surgery, Boston University School of Medicine (T.D.), Boston, Massachusetts; Department of Trauma, Ventura County Medical Center (T.K.D.), Ventura, California; Critical Care and Emergency General Surgery, NYU-Winthrop Hospital (D'A.K.J.), Mineola, New York; Department of Surgery, University of Texas Health Science Center (R.M.S.), San Antonio, Texas; and Center for Surgery and Public Health, Brigham and Women's Hospital (Z.R.C.), Boston, Massachusetts.

An effective injury prevention program is an important component of a successful trauma system. Maintaining support for a hospital-based injury prevention program is challenging, given competing institutional and trauma program priorities and limited resources. In light of those pressures, the American College of Surgeons Committee on Trauma mandates that trauma centers demonstrate financial support for an injury prevention program as part of the verification process, recognizing that hospital administrators might see such support as discretionary and ripe as a target for expense reduction efforts. This Topical Update from the American Association for the Surgery of Trauma Injury Prevention Committee focuses on strategies to be more effective with the limited resources that are allocated to hospital-based injury prevention programs. First, this review tackles two of the many social determinates of violence, including activities aimed at mitigating the impact of both community violence exposure and intimate partner/domestic violence. Developing or participating in coalitions for injury prevention, both in general with any injury prevention initiative, and specifically while developing a hospital-based violence intervention program, efficiently extends the hospital's efforts by gaining access to expertise, resources, and influence over the target population that the hospital might otherwise have difficulty impacting. Finally, the importance of systematic program evaluation is explored. In an era of dwindling resources for injury prevention, both at the national level and the institutional level, it is important to measure the effectiveness of injury prevention efforts on the target population, and when necessary, make changes to programs to both improve their effectiveness and to assist organizations in making wise choices in the use of their limited resources.
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http://dx.doi.org/10.1097/TA.0000000000002313DOI Listing
August 2019

Multi-Institutional Multidisciplinary Injury Mortality Investigation in the Civilian Pre-Hospital Environment (MIMIC): a methodology for reliably measuring prehospital time and distance to definitive care.

Trauma Surg Acute Care Open 2019 11;4(1):e000309. Epub 2019 Apr 11.

Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA.

The detailed study of prehospital injury death is critical to advancing trauma and emergency care, as circumstance and causality have significant implications for the development of mitigation strategies. Though there is no true 'Golden Hour,' the time from injury to care is a critical element in the analysis matrix, particularly in patients with severe injury. Currently, there is no standard method for the assessment of time to definitive care after injury among prehospital deaths. This article describes a methodology to estimate total prehospital time and distance for trauma patients transported via ground emergency medical services and helicopter emergency medical services using a geographic information system. Data generated using this method, along with medical examiner and field investigation reports, will be used to estimate the potential survivability of prehospital trauma deaths occurring in five US states and the District of Columbia as part of the Multi-Institutional Multidisciplinary Injury Mortality Investigation in the Civilian Pre-Hospital Environment study. One goal of this work is to develop standard metrics for the assessment of total prehospital time and distance, which can be used in the future for more complex spatial analyses to gain a deeper understanding of trauma center access. Results will be used to identify high priority areas for research and development in injury prevention, trauma system performance improvement, and public health.
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http://dx.doi.org/10.1136/tsaco-2019-000309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6461208PMC
April 2019

Firearm injury research and epidemiology: A review of the data, their limitations, and how trauma centers can improve firearm injury research.

J Trauma Acute Care Surg 2019 Sep;87(3):678-689

From the Department of Surgery, Division of Trauma, Burn and Critical Care Surgery, Harborview Medical Center (A.B.H.), University of Washington, Seattle, Washington; Department of Surgery, Division of Trauma and Critical Care Surgery (S.B.), Rutgers New Jersey Medical School, Newark, New Jersey; Department of Surgery (M.L.), Arnold Palmer Hospital For Children, Orlando Health, Orlando, Florida; Division of Acute Care Surgery, Department of Surgery (D.A.K.), University of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada; Department of Surgery, Acute Care and Trauma Surgery (L.A., P.A.B.), Boston University School of Medicine, Boston, Massachusetts; Division of Acute Care Surgery, Department of Surgery (J.S.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery (E.M.B.), Harborview Medical Center, University of Washington, Seattle, Washington; and Division of Trauma and Emergency Surgery, Department of Surgery (R.M.S.), University of Texas Health Science Center at San Antonio, San Antonio, Texas.

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http://dx.doi.org/10.1097/TA.0000000000002330DOI Listing
September 2019

Give the trauma patient what they bleed, when and where they need it: establishing a comprehensive regional system of resuscitation based on patient need utilizing cold-stored, low-titer O+ whole blood.

Transfusion 2019 04;59(S2):1429-1438

Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas.

Background: Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting. Military studies clearly identify hemorrhage as the leading cause of potentially survivable prehospital death. Shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured.

Materials And Methods: Our regional trauma network (Southwest Texas Regional Advisory Council) developed and implemented a multiphased approach toward facilitating remote damage control resuscitation. This approach required placing low-titer O+ whole blood (LTO+ WB) at helicopter emergency medical service bases, transitioning hospital-based trauma resuscitation from component therapy to the use of whole blood, modifying select ground-based units to carry and administer whole blood at the scene of an accident, and altering the practices of our blood bank to support our new initiative. In addition, we had to provide information and training to an entire large urban emergency medical system regarding changes in policy.

Results: Through a thorough, structured program we were able to successfully implement point-of-injury resuscitation with LTO+ WB. Preliminary evaluation of our first 25 patients has shown a marked decrease in mortality compared to our historic rate using component therapy or crystalloid solutions. Additionally, we have had zero transfusion reactions or seroconversions.

Conclusion: Transfusion at the scene within minutes of injury has the potential to save lives. As our utilization expands to our outlying network we expect to see a continued decrease in mortality among significantly injured trauma patients.
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http://dx.doi.org/10.1111/trf.15264DOI Listing
April 2019

A prospective study in severely injured patients reveals an altered gut microbiome is associated with transfusion volume.

J Trauma Acute Care Surg 2019 04;86(4):573-582

From the Department of Surgery (S.E.N., T.R.J., S.S., M.D.R., R.B.J., D.R.M., C.Z., L.M.N., R.M.S., M.G.S., D.H.J., B.J.E.), UT Health San Antonio; Greehey Children's Cancer Research Institute (Y.Z., Z.L.), Department of Molecular Medicine (Z.L.), UT Health San Antonio; and the U.S. Army Institute of Surgical Research (D.M.B.), Fort Sam Houston, San Antonio, Texas.

Background: Traumatic injury can lead to a compromised intestinal epithelial barrier and inflammation. While alterations in the gut microbiome of critically injured patients may influence clinical outcomes, the impact of trauma on gut microbial composition is unknown. Our objective was to determine if the gut microbiome is altered in severely injured patients and begin to characterize changes in the gut microbiome due to time and therapeutic intervention.

Methods: We conducted a prospective, observational study in adult patients (n = 72) sustaining severe injury admitted to a Level I Trauma Center. Healthy volunteers (n = 13) were also examined. Fecal specimens were collected on admission to the emergency department and at 3, 7, 10, and 13 days (±2 days) following injury. Microbial DNA was isolated for 16s rRNA sequencing, and α and β diversities were estimated, according to taxonomic classification against the Greengenes database.

Results: The gut microbiome of trauma patients was altered on admission (i.e., within 30 minutes following injury) compared to healthy volunteers. Patients with an unchanged gut microbiome on admission were transfused more RBCs than those with an altered gut microbiome (p < 0.001). Although the gut microbiome started to return to a β-diversity profile similar to that of healthy volunteers over time, it remained different from healthy controls. Alternatively, α diversity initially increased postinjury, but subsequently decreased during the hospitalization. Injured patients on admission had a decreased abundance of traditionally beneficial microbial phyla (e.g., Firmicutes) with a concomitant decrease in opportunistic phyla (e.g., Proteobacteria) compared to healthy controls (p < 0.05). Large amounts of blood products and RBCs were both associated with higher α diversity (p < 0.001) and a β diversity clustering closer to healthy controls.

Conclusion: The human gut microbiome changes early after trauma and may be aided by early massive transfusion. Ultimately, the gut microbiome of trauma patients may provide valuable diagnostic and therapeutic insight for the improvement of outcomes postinjury.

Level Of Evidence: Prognostic and Epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6433524PMC
April 2019

Developing a national trauma system: Proposed governance and essential elements.

J Trauma Acute Care Surg 2018 09;85(3):637-641

From the Weill Cornell Medicine, New York, NY (R.J.W.); University of Texas Health Science Center at San Antonio San Antonio, Texas (B.J.E., R.M.S. ); University Medical Center New Orleans, New Orleans, Louisiana (M.M.M.); Medical Center Navicent Health, Macon, Georgia (D.W.A.); University of Pittsburgh School of Medicine, Pittsburg, Pennsylvania (B.A.G); National Association of State EMS Officials, Falls Church, Virginia (D.G.); Vanderbilt University Medical Center, Nashville, Tennessee (A.A.J.); Rothman Institute of Orthopaedics, Philadelphia, Pennsylvania (J.C.K.); Maryland Institute for Emergency Medical Services Systems (MIEMSS), Baltimore, Maryland (C.A.M.); American College of Surgeons, Chicago, Illinois (H.N.M.); Jackson Memorial Hospital, Miami, Florida (N.N.); University of Virginia, Charlottesville, Virginia (D.G.P.); and Harborview Medical Center, Seattle, Washington (E.M.B.).

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http://dx.doi.org/10.1097/TA.0000000000001994DOI Listing
September 2018

Freedom with Responsibility: A Consensus Strategy for Preventing Injury, Death, and Disability from Firearm Violence.

J Am Coll Surg 2018 08 19;227(2):281-283. Epub 2018 Apr 19.

Department of Surgery, University of Washington, Seattle, WA.

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http://dx.doi.org/10.1016/j.jamcollsurg.2018.04.006DOI Listing
August 2018

Failure on the American Board of Surgery Examinations of General Surgery Residency Graduates Correlates Positively with States' Malpractice Risk.

Am Surg 2018 Mar;84(3):398-402

It has been suggested that in environments where there is greater fear of litigation, resident autonomy and education is compromised. Our aim was to examine failure rates on American Board of Surgery (ABS) examinations in comparison with medical malpractice payments in 47 US states/territories that have general surgery residency programs. We hypothesized higher ABS examination failure rates for general surgery residents who graduate from residencies in states with higher malpractice risk. We conducted a retrospective review of five-year (2010-2014) pass rates of first-time examinees of the ABS examinations. States' malpractice data were adjusted based on population. ABS examinations failure rates for programs in states with above and below median malpractice payments per capita were 31 and 24 per cent (P < 0.01) respectively. This difference was seen in university and independent programs regardless of size. Pearson correlation confirmed a significant positive correlation between board failure rates and malpractice payments per capita for Qualifying Examination (P < 0.02), Certifying Examination (P < 0.02), and Qualifying and Certifying combined index (P < 0.01). Malpractice risk correlates positively with graduates' failure rates on ABS examinations regardless of program size or type. We encourage further examination of training environments and their relationship to surgical residency graduate performance.
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March 2018

Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury.

J Trauma Acute Care Surg 2018 06;84(6S Suppl 1):S115-S119

From the Department of Surgery (A.C.M., R.J., S.E.N., B.J.E., R.M.S., D.H.J.), UT Health San Antonio; College of Sciences (C.S.Z.), UT San Antonio; Department of Pathology (L.G.), Department of Obstetrics and Gynecology (E.X.), UT Health San Antonio; The Blood & Tissue Center Foundation South Texas Blood and Tissue Center (E.W.); Southwest Texas Regional Advisory Council (E.E.), San Antonio, Texas; and General Surgery (D.C.), Louisiana State University School of Medicine, New Orleans, Louisiana.

The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival. These truths, balanced with the availability of local resources and our goals for positive regional impact, were the foundation for the development of our prehospital whole blood initiative-using low-titer cold-stored O RhD-positive whole blood. The main concern with use of RhD-positive blood is the potential development of isoimmunization in RhD-negative patients. We used our retrospective massive transfusion protocol (MTP) data to analyze the anticipated risk of this change in practice. In 30 months, of 124 total MTP patients, only one female of childbearing age that received an MTP was RhD-negative. With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that the utilization of low-titer cold-stored O RhD-positive whole blood would be safe and best serve our community.
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http://dx.doi.org/10.1097/TA.0000000000001905DOI Listing
June 2018

Implementation of a National Trauma Research Action Plan (NTRAP).

J Trauma Acute Care Surg 2018 06;84(6):1012-1016

From the University of Washington, Seattle, Washington (E.M.B.); Uniformed Services University of Health Sciences, Bethesda, Maryland (T.E.R.); University of California-Davis, Sacramento, California (G.J.J.); University of Tennessee Health Sciences Center, Memphis, Tennessee (T.C.F.); Maryland Shock Trauma Institute, Baltimore, Maryland (R.A.K.); University of California-San Diego, San Diego, California (R.C., T.W.C.); Johns Hopkins University, Baltimore, Maryland (J.F.); University of Vermont, Burlington, Vermont (A.K.M.); National Trauma Institute, San Antonio, Texas (M.A.P., S.L.S.); Brown University, Providence, Rhode Island (W.G.C.); University of Texas Health Science Center, San Antonio, Texas (R.M.S.).

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http://dx.doi.org/10.1097/TA.0000000000001812DOI Listing
June 2018
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