Social Determinants of Health Associated With the Need for Urgent Versus Elective Cholecystectomy at an Urban, Safety-Net Hospital

Background: Benign gallstone disease is the most frequent indication for cholecystectomy in the United States. Many patients present with complicated disease requiring urgent interventions, which increases morbidity and mortality. We investigated the association between individual and population-level social determinants of health (SDoH) with urgent versus elective cholecystectomy. Patients and Methods: All patients undergoing cholecystectomy (2014-2021) for benign gallstone disease were included. Demographic and clinical data were linked to population-level SDoH characteristics using census tracts. Data were analyzed using descriptive and inferential statistics. Results: A total of 3,197 patients met inclusion criteria; 1,913 (59.84%) underwent urgent cholecystectomy, 1,204 (37.66%) underwent emergent cholecystectomy, and 80 (2.5%) underwent interval cholecystectomy. On multinomial logistic regression, patients who were older (relative risk [RR], 1.010; p < 0.001), black (RR, 1.634; p = 0.008), and living in census tracts with a higher percent of poverty (RR, 0.017; p = 0.021) had a higher relative risk of presenting for urgent cholecystectomy. Patients who were female (RR, 0.462; p < 0.001), had a primary care provider (PCP; RR, 0.821; p = 0.018), and lived in census tracts with low supermarket access (RR, 0.764; p = 0.038) had a lower relative risk of presenting for urgent cholecystectomy. Only age (RR, 1.066; p < 0.001), female gender (RR, 0.227; p < 0.001), and having a PCP (RR, 1.984; p = 0.034) were associated with presentation for interval cholecystectomy. Conclusions: Patients who were older, black, and living in census tracts with high poverty levels had a higher relative risk of presenting for urgent cholecystectomy at our institution, whereas females and patients with PCPs were more likely to undergo elective cholecystectomy. Improved access to primary care and surgical clinics for all patients at safety-net hospitals may result in improved outcomes in the management of benign gallstone disease by increasing diagnosis and treatment in the elective setting.

Standing in Unity Amidst Change: A Group Mentorship Model that Addresses the Logistical and Emotional Needs of Applicants for Surgical Residency

OBJECTIVE

For medical students, applying to general surgery residency is a complex and multifactorial process that can be fraught with significant challenges. The COVID-19 pandemic generated additional uncertainty and distress for applicants given the temporary suspension of in-person clinical rotations and transition to virtual residency interviews. However, despite the significant changes introduced by the COVID-19 pandemic, our group mentorship model - originally developed to address the emotional and logistical needs of applicants - withstood national shifts in medical education. In this manuscript, we detail the rationale and design of our group mentorship model for fourth-year medical students with the hopes that other programs may implement our current resources and acquire insight from the lessons we learned amidst responding to the changing climate in surgical education.

DESIGN

Implementation of a longitudinal program utilizing a group mentorship model to provide students with emotional and logistical support during the residency application process.

SETTING

This program was implemented at the Boston University Chobanian & Avedisian School of Medicine.

PARTICIPANTS

Fourth-year medical students that are applying to general surgery residency.

RESULTS

The program consisted of 11 sessions, ranging from 1-2 hours in duration, and approximately 14-17 students participated in the program per year. The program was led by a mentor panel that consisted of a faculty advisor, resident physicians, and appointed student liaisons.

CONCLUSIONS

Group mentorship is a unique model that allows for multidirectional dissemination of advice and experiences amidst student participants and mentors. In times of shifts in medical education, the diverse mentor panel allows for the development of strategies to address unanticipated challenges encountered during the application process.

Gun Laws, Stay-at-Home Orders, and Poverty: Surges in Pandemic Firearm Violence in Large US Cities

INTRODUCTION

The COVID-19 pandemic heralded a surge in firearm homicides (FH) in many, but not all, urban centers. We aimed to determine the relationship of firearm restrictive legislation, stay-at-home orders (SaHOs), and FH during the height of the COVID-19 pandemic in US cities.

METHODS

Demographics and socioeconomic data were captured from the 2020 US Census for large (population ≥250,000) cities. FH data were captured from the Gun Violence Archive. We retrieved firearm recovery estimates from the Bureau of Alcohol, Tobacco, and Firearms Firearms Trace Database. Firearm restrictive legislation was gathered from the State Firearm Laws Database. SaHO durations were found from press releases and government sources. Variables with P ≤ 0.200 in univariate linear regression were entered into a final multivariable model.

RESULTS

A median of 7.5 FH per 100,000 people occurred in the 85 included US cities across 32 states in 2020 (range, 0.35-69.80 per 100,000). In multivariable regression, longer SaHOs (β: 0.033, 95% confidence interval [CI]: 0.014-0.053, P = 0.001) and higher poverty (β: 0.471, 95% CI: 0.280-0.670, P < 0.001) were associated with increases in FH. Handgun-specific laws (β: -0.793, 95% CI: -1.430 to -0.160, P = 0.015) were associated with lower FH.

CONCLUSIONS

We found that poverty and longer SaHOs were associated with increased FH in large US cities during the height of the pandemic, while handgun-specific laws were associated with a decrease. Reducing poverty, mitigating the negative effects of SaHOs, and expanding handgun-specific legislation may protect from surges in FH during future crises.

The effect of historic redlining on firearm violence

BACKGROUND

Firearm homicides disproportionately affect young Black men, which in turn have lasting impact of communities of color as a whole. Previous cross-sectional studies have highlighted the role of discriminatory housing policies on the incidence of urban firearm violence. We sought to estimate the effects of racist housing policies on firearm incidence.

METHODS

Firearm incident data were obtained from the Boston Police Department and point locations spatially joined with vector files outlining the original 1930 Home Owner Loan Corporation (HOLC) Redlining maps. A regression discontinuity design was used to assess the increased rate of firearm violence crossing from historically "desirable" neighborhoods (Green) to historically "hazardous" neighborhoods (Red and Yellow) based on HOLC definitions. Linear regression models were fit on either side of the geographic boundaries with firearm incidents graphed at varying distances and the regression coefficient calculated at the boundary.

RESULTS

Crossing from desirable to Red hazardous designation there was a significant discontinuity with an increase of 4.1 firearm incidents per 1,000 people (95% CI 0.68,7.55). Similarly, when crossing from desirable areas to the Yellow hazardous designation there was a significant discontinuity and increase of 5.9 firearm incidents per 1,000 people (95% CI 1.85,9.86). There was no significant discontinuity between the two hazardous HOLC designations (coefficient -0.93, 95% CI -5.71, 3.85).

CONCLUSIONS

There is a significant increase in firearm incidents in historically redlined areas of Boston. This suggests that interventions should focus on downstream socioeconomic, demographic, and neighborhood detriments of historically discriminatory housing policies in order to address firearm homicides.

Preventing the most common firearm deaths: Modifiable factors related to firearm suicide

BACKGROUND

More than 20,000 firearm suicides occur every year in America. Firearm restrictive legislation, firearm access, demographics, behavior, access to care, and socioeconomic metrics have been correlated to firearm suicide rates. Research to date has largely evaluated these contributors singularly. We aimed to evaluate them together as they exist in society. We hypothesized that state firearm laws would be associated with reduced firearm suicide rates.

METHODS

We acquired the 2013 to 2016 data for firearm suicide rates from The Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research. Firearm laws were obtained from the State Firearms Law Database. Depression rates and access to care were obtained from the Behavioral Risk Factor Surveillance System and Occupational Employment and Wage Statistics program. Population demographics, poverty, and access to social support were obtained from the American Community Survey. Firearm access estimates were retrieved from the National Instant Criminal Background Check System. We used a univariate panel linear regression with fixed effect for state and firearm suicide rates as the outcome. We created a final multivariable model to determine the adjusted associations of these factors with firearm suicide rates.

RESULTS

In univariate analysis, firearm access, heavy drinking behavior, demographics, and access to care correlated to increased firearm suicide rates. The state proportion identifying as white and the proportion of those in poverty receiving food benefits correlated to decreased firearm suicide rates. In multivariable regression, only heavy drinking (β, 0.290; 95% confidence interval, 0.092-0.481; P = .004) correlated to firearm suicides rates increases.

CONCLUSIONS

During our study, few firearm laws changed. Heavy drinking behavior association with firearm suicide rates suggests an opportunity for interventions exists in the health care setting.

Historic redlining, social mobility, and firearm violence

BACKGROUND

Much of the recorded medical literature focuses on individual-level factors that contribute to firearm violence. Recently, studies have highlighted higher incidence of firearm violence in historically redlined and marginalized areas, but few have gone on to study the downstream associations causing these differences. This study aims to understand the effects of historic redlining and current income mobility on firearm violence.

METHODS

Using a retrospective cross-sectional design, shooting incidents were spatially joined with redlining vector files and linked to income mobility data (how much a child makes in adulthood). Participants included all assault and homicide incidents involving a firearm in the city of Boston, between 2016 and 2019. The exposure of interest was redlining designation as outlined by the Home Owner's Loan Corporation (HOLC) in the 1930s and income mobility, stratified by race, defined as the income of a child in their 30s compared with where they grew up (census tract level). The outcome measured was shooting rate per census block.

RESULTS

We find that increases in Black income mobility (BIM) and White income mobility (WIM) are associated with significant decreases in rates of firearm incidents in all HOLC designations; however, there is a larger decrease with increasing BIM (relative risk, 0.47 per unit increase in BIM [95% confidence interval, 0.35-0.64]; relative risk, 0.81 per unit increase in WIM [95% confidence interval, 0.71-0.93]). Plotting predicted rates of firearm violence in each HOLC designation at different levels of BIM, there were no significant differences in shooting rates between historically harmful and beneficial classifications above $50,000 of BIM. Despite level of WIM, there were continued disparities between harmful and beneficial HOLC classification.

CONCLUSION

These findings highlight the importance of structural racism in the form of redlining and discriminatory housing policies, and the preclusion from economic mobility therein, on the incidence of firearm violence today.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Resuscitation of an exsanguinated obstetrics patient with HBOC-201: A case report

BACKGROUND

Hemorrhagic shock is a clinically challenging disease process with high mortality. When conventional blood products are unable to be administered, oxygen-carrying blood alternatives are sometimes utilized. The international experience with this scenario is limited. We aim to add to this body of literature.

STUDY DESIGN AND METHODS

This is a case report of the administration of bovine hemoglobin-based oxygen-carrying red blood cell (RBC) substitute HBOC-201 (HemoPure®) to a patient with post-partum bleeding and hemorrhagic shock because the patient declined RBC transfusion. HBOC-201 was administered with consent under a one-time Emergency Investigational New Drug (eIND) approval from the Food and Drug Administration with appropriate notification of the Institutional Review Board.

RESULTS

The patient was successfully resuscitated with HBOC-201 from hemorrhagic shock. She was weaned off of vasopressor support and extubated with the recovery of her baseline mental status within 4 h. However, approximately 36 h after this, the patient developed multi-organ system dysfunction, volume overload, right heart failure and ultimately expired early on post-partum day 4.

DISCUSSION

Resuscitation from hemorrhagic shock with HBOC-201 as an RBC alternative is feasible, but significant challenges remain with the management of sequelae resulting from prolonged low-flow, ischemic states as well as the significant colloid pressure and volume overload experienced after massive transfusion with an acellular colloid oxygen carrier.

Citizenship and Social Responsibility in Surgery: A Review

Importance

Social determinants of health have been shown to be key drivers of disparities in access to surgical care and surgical outcomes. Though the concept of social responsibility has received growing attention in the medical field, little has been published contextualizing social responsibility in surgery. In this narrative review, we define social responsibility as it relates to surgery, explore the duty of surgeons to society, and provide examples of social factors associated with adverse surgical outcomes and how they can be mitigated.

Observations

The concept of social responsibility in surgery has deep roots in medical codes of ethics and evolved alongside changing views on human rights and the role of social factors in disease. The ethical duty of surgeons to society is based on the ethical principles of benevolence and justice and is grounded within the framework of the social contract. Surgeons have a responsibility to understand how factors such as patient demographics, the social environment, clinician awareness, and the health care system are associated with inequitable patient outcomes. Through education, we can empower surgeons to advocate for their patients, address the causes and consequences of surgical disparities, and incorporate social responsibility into their daily practice.

Conclusions and Relevance

One of the greatest challenges in the field of surgery is ensuring that surgical care is provided in an equitable and sustainable way. Surgeons have a duty to understand the factors that lead to health care disparities and use their knowledge, skills, and privileged position to address these issues at the individual and societal level.

The Impact of Income and Social Mobility on Colorectal Cancer Outcomes and Treatment: A Cross-sectional Study

OBJECTIVE

To determine the impact of income mobility on racial disparities in colorectal cancer.

BACKGROUND

There are well-documented disparities in colorectal cancer treatment and outcomes between Black and White patients. Socioeconomic status, insurance, and other patient-level factors have been shown important, but little has been done to show the discriminatory factors that lead to these outcomes.

METHODS

Data were obtained from the Surveillance Epidemiology and End-Results database for Black and White patients with colorectal cancer between 2005 and 2015. County level measures of Black (BIM) and White income mobility (WIM) were obtained from the Opportunity Atlas as a measure of intergenerational poverty and social mobility. Regression models were created to assess the relative risk of advanced stage at diagnosis (Stage IV), surgery for localized disease (Stage I/II), and cancer-specific mortality.

RESULTS

There was no significant association of BIM or WIM on advanced stage at diagnosis in Black or White patients. An increase of $10,000 of BIM was associated with a 9% decrease in hazards of death for both Black (hazard ratio 0.91, 95% confidence interval 0.86,0.95) and White (0.91, 95%CI 0.90,0.93) patients, while the same increase in WIM was associated with no significant difference in hazards among Black patients (hazard ratio 0.99, 95% confidence interval 0.97,1.02). There were no predicted racial differences in hazards of death at high levels of BIM.

CONCLUSIONS

Increased Black income mobility significantly improves survival for both Black and White patients. Interventions aimed at increasing economic and social mobility could significantly decrease mortality in both Black and White patients while alleviating disparities in outcomes.

Historic redlining, structural racism, and firearm violence: A structural equation modeling approach

Background:

Firearm homicides disproportionately affect Black communities. Redlining – discriminatory lending practices of the early 20^th century - are associated with current increased rates of firearm violence. Poverty and concentrated disadvantage are also associated with firearm violence. The interaction of these factors with racist redlining housing practices remains unclear.

Methods:

We used generalized structural equation modeling to characterize the mediators through which redlining practices of the 1930s led to present rates of firearm violence in Boston using a negative binomial model. Principle component analysis was used to create four distinct mediating variables representing census block socioeconomic and built environment information, while reducing dimensionality. We calculated the direct effect between harmful (Red and Yellow) vs beneficial (Green) designations and firearm incident rate, indirect effect between redlining designation and firearm incident rate through each mediating variable, and the total effect. The percentage mediation of each mediator was subsequently calculated.

Findings:

Red and Yellow areas of Boston were associated with an 11•1 (95% CI 5•5,22•4) and 11•4 (5•7,22•8) increased incident rate of shooting when compared to Green. In the pathway between Red designation and firearm incident rate, poverty and poor educational attainment mediated 20% of the interaction, share of rented housing mediated 8%, and Black share of the population 3%. In the pathway between Yellow designation and firearm incident rate, poverty and poor educational attainment mediated 16% of the association, and Black share of the population mediated 13%.

Interpretation:

Redlining practices of the 1930s potentially contribute to increased rates of firearm violence through changes to neighborhood environments, namely through preclusion from homeownership, poverty, poor educational attainment, and concentration (i.e. segregation) of Black communities. These downstream mediating factors serve as points for policy interventions to address urban firearm violence.

Funding:

Michael Poulson and Miriam Neufeld were supported by T32 Training Grants (HP10028, GM86308).

American Association for the Surgery of Trauma Prevention Committee review: Family Justice Centers-a not-so-novel, but unknown gem

The American College of Surgeons Committee on Trauma requires that trauma centers demonstrate adequate financial support for an injury prevention program as part of the verification process. With the ongoing challenges that arise with important social determinants of health, trauma centers have the important task of navigating a patient through the complex process of obtaining services and tools for success. This summary from the American Association for the Surgery of Trauma Prevention Committee focuses on a model that has been present for several years, but has not been brought to full awareness in the trauma world. It highlights the importance of the Family Justice Center concept that brings a multitude of organizations under one roof, thus eliminating the hurdles encompassed by trauma patients, seeking life-changing resources necessary to mitigate the impact of both community violence exposure and intimate partner/domestic violence. It discusses the potential benefits of a partnership between trauma centers and Family Justice Centers and similar models. Finally, it also raises awareness of important programmatic evaluation research required in the arena of injury prevention targeting a population whose outcomes are difficult to measure.

National Disparities in COVID-19 Outcomes between Black and White Americans

BACKGROUND

There is very limited comprehensive information on disparate outcomes of black and white patients with COVID-19 infection. Reports from cities and states have suggested a discordant impact on black Americans, but no nationwide study has yet been performed. We sought to understand the differential outcomes for black and white Americans infected with COVID-19.

METHODS

We obtained case-level data from the Centers for Disease Control and Prevention on 76,442 white and 48,338 non-Hispanic Black patients diagnosed with COVID-19, ages 0 to >80+, outlining information on hospitalization, ICU admission, ventilation, and death outcomes. Multivariate Poisson regressions were used to estimate the association of race, treating white as the reference group, controlling for sex, age group, and the presence of comorbidities.

RESULTS

Black patients were generally younger than white, were more often female, and had larger numbers of comorbidities. Compared to white patients with COVID-19, black patients had 1.4 times the risk of hospitalization (RR 1.42, p < 0.001), and almost twice the risk of requiring ICU care (RR 1.68, p < 0.001) or ventilatory support (RR 1.81, p < 0.001) after adjusting for covariates. Black patients saw a 1.36 times increased risk of death (RR 1.36, p < 0.001) compared to white. Disparities between black and white outcomes increased with advanced age.

CONCLUSION

Despite the initial descriptions of COVID-19 being a disease that affects all individuals, regardless of station, our data demonstrate the differential racial effects in the United States. This current pandemic reinforces the need to assess the unequal effects of crises on disadvantaged populations to promote population health.

Clinical diagnostic phenotypes in hospitalizations due to self-inflicted firearm injury

BACKGROUND

. Hospitalized self-inflicted firearm injuries have not been extensively studied, particularly regarding clinical diagnoses at the index admission. The objective of this study was to discover the diagnostic phenotypes (DPs) or clusters of hospitalized self-inflicted firearm injuries.

METHODS

. Using Nationwide Inpatient Sample data in the US from 1993 to 2014, we used International Classification of Diseases, Ninth Revision codes to identify self-inflicted firearm injuries among those ≥18 years of age. The 25 most frequent diagnostic codes were used to compute a dissimilarity matrix and the optimal number of clusters. We used hierarchical clustering to identify the main DPs.

RESULTS

. The overall cohort included 14072 hospitalizations, with self-inflicted firearm injuries occurring mainly in those between 16 to 45 years of age, black, with co-occurring tobacco and alcohol use, and mental illness. Out of the three identified DPs, DP1 was the largest (n=10,110), and included most common diagnoses similar to overall cohort, including major depressive disorders (27.7%), hypertension (16.8%), acute post hemorrhagic anemia (16.7%), tobacco (15.7%) and alcohol use (12.6%). DP2 (n=3,725) was not characterized by any of the top 25 ICD-9 diagnoses codes, and included children and peripartum women. DP3, the smallest phenotype (n=237), had high prevalence of depression similar to DP1, and defined by fewer fatal injuries of chest and abdomen.

LIMITATIONS

. Claims data.

CONCLUSIONS

. There were three distinct diagnostic phenotypes in hospitalizations due to self-inflicted firearm injuries. Further research is needed to determine how DPs can be used to tailor clinical care and prevention efforts.

Utilization of mental health services in pediatric patients surviving penetrating trauma resulting from interpersonal violence

BACKGROUND

Violent trauma has lasting psychological impacts. Our institution's Community Violence Response Team (CVRT) offers mental health services to trauma victims. We characterized implementation and determined factors associated with utilization by pediatric survivors of interpersonal violence-related penetrating trauma.

METHODS

Analysis included survivors (0-21 years) of violent penetrating injury at our institution (2011-2017). Injury and demographic data were collected. Nonparametric regression models determined factors associated with utilization.

RESULTS

There was initial rapid uptake of CVRT (2011-2013) after which it plateaued, serving >80% of eligible patients (2017). White race and higher injury severity were associated with receipt and duration of services. In post-hoc analysis, race was found to be associated with continued treatment but not with initial consultation.

CONCLUSION

Successful implementation required three years, aiding >80% of patients. CVRT is a blueprint to strengthen existing violence intervention programs. Efforts should be made to ensure that barriers to providing care, including those related to race, are overcome.

Intersectional Disparities Among Hispanic Groups in COVID-19 Outcomes

Previous geographically limited studies have shown differential impact of COVID-19 on Hispanic individuals. Data were obtained from the Centers for Disease Control and Prevention. We performed multivariate Poisson regression assessing risk of hospitalization and death in Hispanic White (HW), Hispanic Black (HB), and Hispanic Multiracial/Other (HM) groups compared to non-Hispanic Whites (NHW). The relative risk of hospitalization was 1.35, 1.58, and 1.50 (p < 0.001) for HW, HB, and HM individuals respectively when compared to NHW. Relative risk of death was 1.36, 1.72, 1.68 (p < 0.001) times higher in HW, HB, and HM compared to NHW. HW, HB, and HM individuals also had significantly increased risk of requiring mechanical ventilation and ICU admission when compared to NHW. Hispanic individuals are more likely to be hospitalized and die from COVID-19 infection than White, which underscores the need for more precise data and policies aimed at unique Hispanic groups to decrease disparities.

Translational research: turning research into advocacy

The social determinants of health are increasingly being recognized within the trauma community. These determinants are major drivers of health and have a huge impact on access to surgery and surgical disparities. As trauma surgeons, we continue to struggle with optimizing care for our patients with many social needs and struggle with trauma as a chronic disease. As we are now using public health approaches to combat complex issues such as gun violence, it is ideal to view our work in a wider context which includes addressing the root causes of trauma and advocating for our patients and our communities. In addition, we need to teach and mentor this broader approach for our students and residents.

Cocaine-associated hemoperitoneum following atraumatic splenic rupture: a case report and literature review

Introduction

Splenic hematoma or rupture of the spleen is rare in the absence of trauma. This case report with a brief review of the literature is intended to raise awareness of splenic bleeding as an etiology of abdominal pain; it highlights the importance of a detailed social history.

Presentation of case

This report of an otherwise healthy 42-year old man details hemoperitoneum with splenic rupture as a cause for hemorrhage following cocaine use. The patient was managed non-operatively in the surgical intensive care unit. He did not require transfusion and was discharged home on hospital day four with close follow-up.

Discussion

While splenic pathology associated with cocaine use has been described, this case illustrates a novel report of cocaine-associated splenic hemorrhage. A plausible mechanism is transient vasospasm with subsequent bleeding into the infarcted area.

Conclusion

Although uncommon, atraumatic splenic rupture should be recognized early because it is potentially fatal. This case is the first to describe hemoperitoneum of splenic etiology following cocaine use.

Alcohol's Role on the Reliability of Clinical Examination to Rule Out Pelvic Fractures

The objective of this study was to determine if clinical examination accurately ruled out pelvic fractures in intoxicated patients sustaining blunt trauma A prospective comparison of intoxicated (blood alcohol level [BAL] greater than 0.08 g/dL) to nonintoxicated (BAL less than 0.08 g/dL) patients sustaining blunt trauma was performed between February 2004 and March 2007. Clinical factors were compared and subset analysis performed in which patients with factors known to compromise the clinical examination were excluded. Two hundred ninety-six intoxicated patients were compared with 1071 nonintoxicated patients. Intoxicated patients were younger and more often male. Intoxicated patients had a higher heart rate (97.1 beats/min ± 17.9 vs 91.4 beats/min ± 18.7, P < 0.0001) and lower systolic blood pressure (136.2 mmHg ± 21.2 vs 141.9 mmHg ± 26.6, P = 0.0005) than nonintoxicated patients. Intoxicated patients had a lower incidence of pelvic fracture (6.1 vs 10.6%). In subset analysis, the majority of the intoxicated patients did not have exclusion factors on examination and could be evaluated (66.6%). There were eight pelvic fractures diagnosed in this group and no missed injuries on clinical examination (sensitivity 100%). Clinical examination was not compromised by intoxication. Routine pelvic x-rays are not needed in the alert, intoxicated patient sustaining blunt trauma.

Alcohol's role on the reliability of clinical examination to rule out pelvic fractures

The objective of this study was to determine if clinical examination accurately ruled out pelvic fractures in intoxicated patients sustaining blunt trauma A prospective comparison of intoxicated (blood alcohol level [BAL] greater than 0.08 g/dL) to nonintoxicated (BAL less than 0.08 g/dL) patients sustaining blunt trauma was performed between February 2004 and March 2007. Clinical factors were compared and subset analysis performed in which patients with factors known to compromise the clinical examination were excluded. Two hundred ninety-six intoxicated patients were compared with 1071 nonintoxicated patients. Intoxicated patients were younger and more often male. Intoxicated patients had a higher heart rate (97.1 beats/min +/- 17.9 vs 91.4 beats/min +/- 18.7, P < 0.0001) and lower systolic blood pressure (136.2 mmHg +/- 21.2 vs 141.9 mmHg +/- 26.6, P = 0.0005) than nonintoxicated patients. Intoxicated patients had a lower incidence of pelvic fracture (6.1 vs 10.6%). In subset analysis, the majority of the intoxicated patients did not have exclusion factors on examination and could be evaluated (66.6%). There were eight pelvic fractures diagnosed in this group and no missed injuries on clinical examination (sensitivity 100%). Clinical examination was not compromised by intoxication. Routine pelvic x-rays are not needed in the alert, intoxicated patient sustaining blunt trauma.

Anticoagulation and the elderly head trauma patient

We sought to determine the effect of anticoagulation therapy on outcomes in elderly patients with closed head injury. We retrospectively reviewed elderly closed head injury patients (> or = 65 years) comparing 52 patients on warfarin (AC) with 439 patients not on warfarin (NAC) with subsequent 1:3 propensity matching used to analyze comparable groups. The overall AC group had a higher head abbreviated injury score (AIS) (4.0 +/- 0.7 vs 3.8 +/- 0.7, P = 0.04) compared with the NAC group. After propensity matching, 49 AC patients were compared with 147 NAC patients who were similar for age, gender, injury severity score, and head AIS. Admission INR was higher in the AC group compared to the NAC group (2.5 +/- 1.3 vs 1.1 +/- 0.3, P < 0.0001) and the AC group had a higher mortality rate (38.8% AC (19/49) vs 23.1% NAC (34/147), P = 0.04). In the AC group, survivors and nonsurvivors had similar repeat International Normalized Ratio (INR) values (1.57 +/- 0.65 survivors vs 1.8 +/- 0.72 nonsurvivors, P = 0.31). The AC group experienced greater morbidity after trauma and had higher mortality rates than their NAC counterparts. Prevention of injury and more selective use of warfarin in this patient population are essential to decrease mortality.

Clinical examination is superior to plain films to diagnose pelvic fractures compared to CT

We prospectively compared clinical examination (CE) with plain films (PXR) and both tools with CT in patients sustaining blunt trauma. There were 1388 patients who had both PXR and CT of whom 168 (12.1%) were diagnosed with a fracture by CT. CE findings most predictive of fracture included age (OR, 1.025; CI, 1.011-1.039), hip pain (OR, 4.971; CI, 2.508-9.854), internal rotation of the leg (OR, 4.880; CI, 1.980-12.027), or tenderness to palpation over the sacrum (OR, 2.297; CI, 1.144-4.612), over the right or left hip (OR, 3.626; CI, 1.823-7.214), or diffusely throughout the pelvis (OR, 16.445; CI, 4.277-63.237). These factors were still predictive of pelvic fractures even in patients with a Glasgow Coma Scale score less than 13. There were 136 fractures identified by PXR all of which were identified by CE (sensitivity 100% [136 of 136], negative predictive value 100% [619 of 619]). There were six patients with negative clinical examinations and positive CTs (sensitivity 96.4% [162 of 168], negative predictive value 99.03% [613 of 619]), none of which were hemodynamically significant. The sensitivity for PXR compared with CT was 79.17 per cent (133 of 168) and the NPV was 97.2 per cent (1217 of 1252). CE is a reliable way to diagnose pelvic fractures and PXR is a poor screening tool for these injuries compared with CT. Because the majority of patients undergo CT after blunt trauma, routine screening radiographs should be eliminated.

Clinical Examination and its Reliability in Identifying Cervical Spine Fractures

BACKGROUND

The Eastern Association for the Surgery of Trauma (EAST) guidelines recommend that cervical spine (c-spine) radiographic evaluation is unnecessary in the awake, alert blunt trauma patient who is not intoxicated, has no distracting injuries, and demonstrates no tenderness over the c-spine or neurologic deficits. The purpose of this study was to compare the reliability of the clinical examination (CE) with that of computed tomography in identifying the presence of c-spine fractures.

METHODS

We prospectively evaluated 534 blunt trauma patients between February 2004 and January 2005. Positive CE was defined as complaints of neck pain, external trauma of the c-spine or neurologic deficit, tenderness or abnormalities to palpation over the cervical spine. Computed tomography was used to define the accuracy of CE.

RESULTS

There were 52 patients with, and 482 patients without, c-spine fractures. Forty of the 52 patients with fractures were accurately identified by CE for a sensitivity of 76.9% and a negative predictive value (NPV) of 95.7%. In the group with an initial Glasgow Coma Score of 15, 16 of 24 patients with fractures were accurately identified for a sensitivity of 66.7% and an NPV of 96.5%. In the subset of patients who by EAST guidelines would not require any radiographic evaluation, there were 17 fractures and 10 were accurately identified by clinical examination. The sensitivity in this group was 58.8% with an NPV of 96.4%. Four of the seven missed injuries required intervention.

CONCLUSIONS

This trial suggests that with a normal Glasgow Coma Score, CE cannot be relied upon to rule out c-spine fracture. CE is unreliable to diagnose or exclude a cervical spine fracture.

Obesity and outcomes after blunt trauma

BACKGROUND

Obesity has proven to be an independent risk factor of mortality in the intensive care unit (ICU) in both nontrauma and trauma patients. The purpose of this study was to determine whether the detrimental effect of obesity extend to morbidity as well as mortality in the intensive and nonintensive care blunt trauma patients.

METHODS

A retrospective comparison of obese (body mass index [BMI] > 30 kg/m2) to nonobese (BMI < 30 kg/m2) blunt trauma patients was performed between January 2004 and December 2005. Patient demographics, morbidity, mortality and ventilator, ICU, and hospital length of stays were analyzed. Continuous variables were evaluated using the Wilcoxon Rank test and the nominal variables were evaluated using the Fisher's exact test.

RESULTS

A cohort of 338 nonobese patients was compared with 115 obese patients during the study. These groups were similar in age (p = 0.19), gender (p = 0.37), and mechanism (p = 0.13). Their severity of injury were similar, demonstrated by nonsignificant differences in Injury Severity Score (p = 0.45), New Injury Severity Score (p = 0.51), Abdomen Abbreviated Injury Score (AIS; p = 0.49), and head AIS (p = 0.64). The subset of obese patients who never went to the ICU had a slightly longer hospital stay with a p value of 0.055. Overall the mortality rates were not different between the groups (3.5% obese versus 7.1% nonobese, p = 0.26).

CONCLUSIONS

This group of obese blunt trauma patients had similar mortality rates to their leaner counterparts possibly because their complications were minimized. Despite this finding, a subset of obese patients had longer hospital stays which increases the financial burden to the patient and hospital. Effort should be made to facilitate their discharge to avoid complications and minimize cost.

Is blood sugar the next lactate?

This study evaluates whether an initial blood glucose level is similarly predictive of injury severity and outcome as admission lactate in trauma patients. Between February 2004 and June 2005, we prospectively compared patients with presenting blood sugars of < or =150 mg/dL (LBS) with those with blood sugars >150 mg/dL (HBS). Fifty patients had BS above 150 mg/dL, whereas 176 patients were < or = 150 mg/dL. These groups had similar demographics except for age. Injury Severity Score (ISS) of > or = 15 was seen in 56.0 per cent of HBS patients versus 28.4 per cent of LBS patients (P = 0.0006). HBS patients had similar infection rates (12.0% HBS vs. 5.7% LBS, P = 0.13) but a higher mortality (30.0% HBS vs. 5.7% LBS, P < 0.0001). There was a linear relationship between ISS and BS (r2 = 0.18, P < 0.0001) and ISS and lactate (r2 = 0.17, P < 0.0001). Blood sugar trended with the lactate (r = 0.25, P = 0.0001). Hyperglycemic patients were more severely injured with higher mortality. BS correlated with lactate, and because it is easily obtainable, it may serve as a readily available predictor of injury severity and prognosis.

Is Blood Sugar the Next Lactate?

This study evaluates whether an initial blood glucose level is similarly predictive of injury severity and outcome as admission lactate in trauma patients. Between February 2004 and June 2005, we prospectively compared patients with presenting blood sugars of ≤150 mg/dL (LBS) with those with blood sugars >150 mg/dL (HBS). Fifty patients had BS above 150 mg/dL, whereas 176 patients were ≤150 mg/dL. These groups had similar demographics except for age. Injury Severity Score (ISS) of ≥15 was seen in 56.0 per cent of HBS patients versus 28.4 per cent of LBS patients (P = 0.0006). HBS patients had similar infection rates (12.0% HBS vs. 5.7% LBS, P = 0.13) but a higher mortality (30.0% HBS vs. 5.7% LBS, P < 0.0001). There was a linear relationship between ISS and BS (r2 = 0.18, P < 0.0001) and ISS and lactate (r2 = 0.17, P < 0.0001). Blood sugar trended with the lactate (r = 0.25, P = 0.0001). Hyperglycemic patients were more severely injured with higher mortality. BS correlated with lactate, and because it is easily obtainable, it may serve as a readily available predictor of injury severity and prognosis.

Regulation of hyaluronan synthase-2 expression in human intestinal mesenchymal cells: mechanisms of interleukin-1beta-mediated induction

Elevated levels of hyaluronan are associated with numerous inflammatory diseases including inflammatory bowel disease. The purpose of this study was to determine whether a cause and effect relationship might exist among proinflammatory cytokines, IL-1beta, TNF-alpha, IFN-gamma, or transforming growth factor-beta (TGF-beta) and hyaluronan expression in human JDMC and, if so, to identify possible mechanisms involved in the induction of hyaluronan expression. TGF-beta, TNF-alpha, and IFN-gamma had little or no effect on hyaluronan production by these cells. Treatment with IL-1beta induced an approximate 30-fold increase in the levels of hyaluronan in the medium of human jejunum-derived mesenchymal cells. Ribonuclease protection analysis revealed that steady-state transcript levels for hyaluronan synthase (HAS)2 were present at very low levels in untreated cells but increased as much as 18-fold in the presence of IL-1beta. HAS3 transcript levels were also increased slightly by exposure of these cells to IL-1beta. Expression of HAS1 transcripts was not detected under any condition in these cells. IL-1beta induction of hyaluronan expression was inhibited in cells transfected with short interfering RNA corresponding to HAS2 transcripts. Inhibitors of the p38 and ERK1/2 mitogen-activated pathways but not JNK/SAPK blocked the IL-1beta-mediated induction of hyaluronan expression and the increase in HAS2 transcript expression. These results suggest that IL-1beta induction of HAS2 expression involves multiple signaling pathways that act in concert, thus leading to an increase in expression of hyaluronan by jejunum-derived mesenchymal cells.