Race does matter: venous thromboembolism in trauma patients with isolated severe pelvic fractures

Preperitoneal pelvic packing in isolated severe pelvic fractures is associated with higher mortality and venous thromboembolism: A matched-cohort study

INTRODUCTION

Preperitoneal pelvic packing (PPP) has been advocated as a damage control procedure for pelvic fracture bleeding, despite of weak evidence.

METHODS

Matched cohort study, TQIP database. Patients with isolated severe blunt pelvic fractures (pelvis abbreviated injury score [AIS] ​≥ ​3, AIS ≤2 in all other body regions) were included. Patients who underwent PPP were matched to patients with no PPP, 1:3 nearest propensity score. Matching was performed based on demographics, vital signs on admission, comorbidities, injury characteristics, type and timing of initiation of VTE prophylaxis, and additional procedures including laparotomy, REBOA, and angioembolization.

RESULTS

64 patients with PPP were matched with 182 patients with No-PPP. PPP patients had higher in-hospital mortality (14.1 ​% vs 2.2 ​% p ​< ​0.001) and higher rates of VTE and DVT (VTE: 14.1 ​% vs 4.4 ​% p ​= ​0.018, DVT: 10.9 ​% vs 2.2 ​% p ​= ​0.008).

CONCLUSION

PPP is associated with worse survival outcomes and increased rate of VTE and DVT complications.

Heparin therapy in sepsis and sepsis-associated disseminated intravascular coagulation: a systematic review and meta-analysis

BACKGROUND

Sepsis is a life-threatening condition that affects 49 million people annually. Managing sepsis-associated coagulopathy poses a significant challenge due to its high mortality rates in intensive care. Recent reports suggest that administering heparin may offer potential survival benefits in sepsis and coronavirus disease cases. However, there is currently no established evidence supporting the use of heparin for sepsis. Thus, in this study, we aimed to assess the efficacy of heparin administration in patients with sepsis.

METHODS

A systematic review was conducted following the PRISMA guidelines. The searches included MEDLINE, Cochrane, and Japanese databases up to January 2023. The inclusion criteria consisted of randomized control trials (RCTs) involving adult sepsis patients receiving heparin. The risk of bias was assessed using RoB2, and the data extraction included 28-day mortality and bleeding complications.

RESULTS

Out of 1733 initial articles, only three studies met the inclusion criteria. The analysis, which included 426 patients, showed no significant difference in 28-day and in-hospital mortality between the heparin and control groups (risk ratio [RR] = 0.86, 95% confidence interval [CI]: 0.60-1.24). Subgroup analysis of sepsis-associated disseminated intravascular coagulation (DIC) patients (n = 109) also did not show a significant reduction in mortality (RR = 0.84, 95% CI: 0.51-1.38). Heterogeneity was zero, and no publication bias was observed. Additionally, there was significant difference in bleeding complications (RR = 0.49, 95% CI: 0.24-0.99, p = 0.047).

CONCLUSIONS

This meta-analysis did not demonstrate a survival benefit of heparin administration in patients with sepsis and sepsis-associated DIC. Further investigation into the potential benefits of heparin is warranted. Moreover, the analysis revealed no increase in bleeding risks with heparin administration; instead, a significant reduction in the risk of bleeding was noted.

TRIAL REGISTRATION

This review was preregistered with PROSPERO (registration: CRD42023385091).

Differences in Perioperative Metrics by Race and Ethnicity and Insurance After Pelvic Fracture: A Nationwide Study

BACKGROUND

Disparities in orthopedic trauma care have been reported for racial-ethnic minority and socially disadvantaged patients. We examined differences in perioperative metrics by patient race and ethnicity and insurance after pelvic fracture in a national sample in the United States.

MATERIALS AND METHODS

The 2016-2019 National Inpatient Sample was queried for White, Black, and Hispanic patients 18 to 64 years old with private, Medicaid, or self-pay insurance who underwent non-elective pelvic fracture surgery. Associations between combined race and ethnicity and insurance subgroups and perioperative metrics (time to surgery, length of stay, inhospital complications, institutional discharge) were assessed using multivariable generalized linear and logistic regression models. Adjusted percent differences or odds ratios (ORs) were reported.

RESULTS

A weighted total of 14,375 surgeries were included (68.8% in White patients, 16.1% in Black patients, and 15.1% in Hispanic patients; 60.0% private insurance, 26.3% Medicaid, and 13.7% self-pay). Compared with White patients with private insurance, all Black insurance subgroups had longer length of stay (+15.38% to +38.78%, P≤.001), as did Hispanic patients with Medicaid (+28.03%, P<.001), White patients with Medicaid (+13.08%, P<.001), and White patients with self-pay (+9.47%, P=.04). Additionally, compared with White patients with private insurance, decreased odds of institutional discharge were observed for all patients with self-pay (OR, 0.24-0.37, P<.001) as well as White patients with Medicaid (OR, 0.70, P=.003) and Hispanic patients with Medicaid (OR, 0.57, P=.002). There were no significant adjusted associations between race and ethnicity and insurance subgroups and in-hospital complications or time to surgery.

CONCLUSION

These differences in perioperative metrics, primarily for Black patients and patients with self-pay insurance, warrant further examination to identify whether they reflect disparities that should be addressed to promote equitable orthopedic trauma care. [Orthopedics. 2024;47(5):e233-e240.].

Surgery on admission and following day reduces hip fracture complications: a Japanese DPC study

INTRODUCTION

The efficacy of early surgery in preventing complications among Japanese elderly patients with hip fractures requires further investigation. This study aims to use a comprehensive Japanese hip fracture case database to determine whether surgery within the day of admission and the following day reduces the incidence of complications and mortality during hospitalization in elderly hip fracture patients.

MATERIALS AND METHODS

We retrospectively analyzed the Japanese National Administrative DPC (Diagnosis Procedure Combination) database from April 2016 to March 2022. Approximately 1100 DPC-affiliated hospitals consistently provided medical records with consent for research. The study investigated the association between postoperative pneumonia, deep vein thrombosis, pulmonary embolism, and mortality during hospitalization after propensity score matching, focusing on surgeries conducted on the day of admission and the following day.

RESULTS

After one-to-one propensity score matching for age, gender, and comorbidity, we identified 146,441 pairs of patients who underwent surgery either within the day of admission and the following day or after the third day of admission. Surgery on the third day or later was independently associated with increased risks of pneumonia, deep vein thrombosis, pulmonary embolism, and mortality during hospitalization with risk ratios of 1.367 (95% CI 1.307-1.426), 1.328 (95% CI 1.169-1.508), 1.338 (95% CI 1.289-1.388), and 1.167 (95% CI 1.103-1.234), respectively.

CONCLUSION

A comprehensive study of elderly Japanese patients with hip fractures in the DPC database showed that surgery on admission and the following day is crucial for preventing complications like pneumonia, deep vein thrombosis, pulmonary embolism, and mortality during hospitalization.

Racial and Ethnic Disparities in Providing Guideline-Concordant Care After Hip Fracture Surgery

Importance

Institutions have adopted protocol-driven standardized hip fracture programs (SHFPs). However, concerns persist regarding bias in adherence to guideline-concordant care leading to disparities in implementing high-quality care for patients recovering from surgery for hip fracture.

Objective

To assess disparities in the implementation of guideline-concordant care for patients after hip fracture surgery in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Hip Fracture (THF) Database.

Design, Setting, and Participants

This cross-sectional study was conducted using the ACS-NSQIP THF database from 2016 to 2021 for patients aged 65 years and older with hip fractures undergoing surgical fixation. Care outcomes of racial and ethnic minority patients (including American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, or multiple races and Hispanic ethnicity) were compared with non-Hispanic White patients via risk difference, stratified by care institution SHFP status. Modified Poisson regression was used to measure interactions. Statistical analysis was performed from November 2022 to June 2024.

Main Outcomes and Measures

The primary outcomes of interest encompassed weight-bearing as tolerated (WBAT) on postoperative day 1 (POD1), venous thromboembolism (VTE) prophylaxis, bone-protective medication, and the presence of SHFP at the institution.

Results

Among 62 194 patients (mean [SD] age, 82.4 [7.3] years; 43 356 [69.7%] female) who met inclusion criteria and after multiple imputation, 11.2% (95% CI, 10.8%-11.5%) were racial and ethnic minority patients, 3.3% (95% CI, 3.1%-3.4%) were Hispanic patients, and 92.0% (95% CI, 91.7%-92.2%) were White. Receiving care at an institution with an SHFP was associated with improved likelihood of receiving guideline-concordant care for all patients to varying degrees across care outcomes. SHFP was associated with higher probability of being WBAT-POD1 (risk difference for racial and ethnic minority patients, 0.030 [95% CI, 0.004-0.056]; risk difference for non-Hispanic White patients, 0.037 [95% CI, 0.029-0.45]) and being prescribed VTE prophylaxis (risk difference for racial and ethnic minority patients, 0.066 [95% CI, 0.040-0.093]; risk difference for non-Hispanic White patients, 0.080 [95% CI, 0.071-0.089]), but SHFP was associated with the largest improvements in receipt of bone-protective medications (risk difference for racial and ethnic minority patients, 0.149 [95% CI, 0.121-0.178]; risk difference for non-Hispanic White patients, 0.181 [95% CI, 0.173-0.190]). While receiving care at an SHFP was associated with improved probability of receiving guideline-concordant care in both race and ethnicity groups, greater improvements were seen among non-Hispanic White patients compared with racial and ethnic minority patients.

Conclusions and Relevance

Older adults who received care at an institution with an SHFP were more likely to receive guideline-concordant care (bone-protective medication, WBAT-POD1, and VTE prophylaxis), regardless of race and ethnicity. However, the probability of receiving guideline-concordant care at an institution with an SHFP increased more for non-Hispanic White patients than racial and ethnic minority patients.

Racial Distribution and Associated Outcomes for Patients With and Without Severe-Isolated Traumatic Brain Injuries Following Venous Thromboembolism Prophylaxis

INTRODUCTION

Disparities in venous thromboembolism (VTE) incidence and prophylaxis have been observed across racial groups. This study investigates the relationship between race, injury type, and the timing of VTE prophylaxis in severe trauma patients, both with and without isolated traumatic brain injuries. The primary goal is to analyze how these factors interact and their potential impact on clinical outcomes.

METHODS

A retrospective cohort study of the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) from 2018 to 2021. Patient demographics, injury categories, VTE prophylaxis timing, injury severity, and in-hospital complications were collected. Multivariable regression models explored associations between race, injury type, VTE prophylaxis, and in-hospital mortality. Groups were analyzed by injury profile (isolated TBI vs non-TBI) and then by VTE prophylaxis timing (early ≤24 hours, late >24 hours).

RESULTS

Of 68,504 trauma patients analyzed, the majority were non-Hispanic or Latino (83.3%), White (71.2%), and male (69.6%). Patients receiving late VTE prophylaxis had higher rates of DVT and PE across race groups than patients with early prophylaxis. Logistic regression showed Asian patients with TBI receiving early prophylaxis were significantly more likely to have in-hospital mortality (OR 16.27, CI = 1.11-237.43, P = .04) than other races.

CONCLUSION

Patients who received late prophylaxis had higher VTE rates than early prophylaxis, independent of injury pattern or race. Additionally, assessing the implications of race in early VTE prophylaxis for isolated TBI showed that adult Asian patients had 16 times higher odds of in-hospital mortality compared to other races.

Risk assessment scales to predict risk of lower extremity deep vein thrombosis among multiple trauma patients: a prospective cohort study

BACKGROUND

Deep vein thrombosis (DVT) is a common complication in orthopedic patients. Previous studies have focused on major orthopedic surgery.There are few studies with multiple trauma. We aimed to describe the prevalence of DVT and compare the predictive power of the different risk assessment scales in patients with multiple trauma.

METHODS

This prospective cohort study involved multiple trauma patients admitted to our hospital between October 2021 and December 2022. Data were prospectively collected for thrombotic risk assessments using the Risk Assessment Profile for thromboembolism(RAPT), the DVT risk assessment score (DRAS), and the Trauma Embolic Scoring System (TESS), respectively. The receiver operation characteristic (ROC) curve and the area under the curve (AUC) were evaluated to compare the predictive power. The whole leg duplex ultrasound of both lower extremities Doppler ultrasound was used to determine DVT incidence.

RESULTS

A total of 210 patients were included, and the incidence of DVT was 26.19%. Distal DVT accounted for 87.27%; postoperative DVT, 72.73%; and bilateral lower extremity thrombosis, 30.91%. There were significant differences in age, education degree, pelvic fracture, surgery, ISS, D-dimer level, length of hospital stay and ICU stay between the thrombosis group and the non-thrombosis group. The AUCs for RAPT, DRAS, and TESS were 0.737, 0.710, and 0.683, respectively. There were no significant differences between the three ROC curves.

CONCLUSIONS

The incidence of DVT was relatively high during hospitalization. We prospectively validated the tests to predict risk of DVT among patients with multiple trauma to help trauma surgeons in the clinical administration of DVT prophylaxis.