Faculty Bibliography

OBJECTIVES: We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York City's (NYC's) central business district. METHODS: Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses. RESULTS: Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723). CONCLUSIONS: Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs. (Am J Public Health. Published online ahead of print August 13, 2015: e1-e6. doi:10.2105/AJPH.2015.302738).

BACKGROUND: Elderly trauma patients (TPs) are the fastest growing trauma population, increasing the need for postacute care rehabilitation. For TP, discharge to skilled nursing facilities (SNFs) has been associated with higher 1-year mortality compared with discharge to inpatient rehabilitation facilities (IRFs) or home. The availability of IRF beds has been decreasing, but the proportion occupied by non-TPs, specifically stroke patients (SPs), has increased. We wanted to better characterize trends in trauma discharges and compare them with a population that is equally dependent on postdischarge rehabilitation. We hypothesized that discharge to SNF is rapidly increasing, while discharge to IRF is declining for trauma, but not for SPs. METHODS: This is retrospective cohort study of adult trauma and SPs discharged from 2003 to 2009. The National Trauma Data Bank and National Inpatient Sample were used to study TPs and SPs, respectively. RESULTS: Falls became the leading cause of injury, and the proportion of older TPs increased from 23% to 30%. Older TPs discharged to SNF increased from 30.7% in 2003 to 40.8% in 2009 (p < 0.001). TPs were 34% (adjusted relative risk [RR], 1.34; 95% confidence interval [CI], 1.15-1.57) more likely to be discharged to an SNF and 36% (adjusted RR, 0.64; 95% CI, 0.48-0.85) less likely to be discharged to an IRF. From 2003 to 2009, SPs were 78% more likely to be discharged to an IRF (adjusted RR, 1.78; 95% CI, 1.74-1.82). The largest absolute increase in SP discharges to IRFs occurred the year following implementation of the stroke center certification program. CONCLUSION: For TPs, there was a significant increase in SNF discharges and a decrease in IRF discharges. During the same period, after implementation of stroke center certification, SPs were more likely to be discharged to an IRF. Future research should focus on evaluating which postacute care setting is most effective in providing rehabilitation for TPs and adjusting our discharge efforts to improve long-term outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

BACKGROUND: The surgical population is aging, and greater numbers of surgical patients are being discharged to skilled nursing facilities. Post-acute care is a poorly understood but very important aspect of our healthcare system. METHODS: This systematic review examines the current body of literature surrounding the structural, process of care, and outcomes measurements for patients in skilled nursing facilities. English language articles published between 1998 and 2011 that purposed to examine nursing facility structure, process of care, and/or outcomes were included. RESULTS & CONCLUSIONS: Abstracts (2129) were screened and 102 articles were reviewed in full. Twenty-nine articles were included in the qualitative synthesis. The role of the care setting and care delivery in contributing to outcomes has not been well studied, and no strong conclusions can be made. This area of care currently represents a "black box" to practicing surgeons. An understanding of these factors maybe instrumental to determining future directions for research to maximize positive outcomes for these patients.

BACKGROUND: This study was designed to examine the characteristics of pedestrian and bicyclist collisions with motor vehicles within New York City's high-density hub. The primary objectives were to map crash locations and to identify hot spots within these injury clusters. The secondary objective was to quantify differences in injury severity based on road type and user behaviors. METHODS: Between December 2008 and June 2011, data were prospectively collected from pedestrians and bicyclists struck by motor vehicles and brought to Bellevue Hospital, a Level 1 trauma center in New York City. Behaviors by cohort (i.e., crossing patterns for pedestrians, riding patterns for bicyclists), Injury Severity Score (ISS), and collision locations were extracted from the database. Analyses of mean ISS were performed using a Student's t test with a p < 0.05 considered significant. Geomaps were created to identify clusters or "hot spots," where higher volumes of crashes occurred over time. Spatial analysis was performed to demonstrate whether these were random events. RESULTS: A total of 1,457 patients (1,075 pedestrians and 382 bicyclists) were enrolled. Collision locations were known for 97.5%. Of the injured pedestrians, those crossing avenues (n = 277) had higher ISSs than those crossing streets (n = 522) (p = 0.01) and were more likely to die (p = 0.002). Pedestrians crossing midblock (n = 185) had higher mean ISSs than those crossing with the signal in the crosswalk (n = 320) (8.12 vs. 5.01, p < 0.001). Based on density mapping, hot spots of pedestrian collisions were detected in midtown Manhattan, while hot spots for bicyclists were detected at bridge and tunnel portals. Spatial analysis indicates that these are not random events (p < 0.05). CONCLUSION: Pedestrians injured on avenues sustained more serious injuries than those injured on narrower streets. A better understanding of collision locations and features may allow for tailored injury prevention strategies. Trauma centers serve an important role in public health surveillance within their local communities. LEVEL OF EVIDENCE: Epidemiologic study, level III.

BACKGROUND: For older adults, even ground-level falls (GLFs) can result in multiple injuries and are associated with significant morbidity and mortality. Previous studies have focused on in-hospital outcomes and patients with isolated injuries. Our study examined outcomes following discharge for older adults who were hospitalized following a GLF. METHODS: A retrospective cohort study of patients older than 65 years admitted to a regional Level I trauma center, from 2005 to 2008, after a GLF was conducted. Hospital trauma registry data were linked to state hospital discharge data and the death certificate registry. Skilled nursing facilities (SNFs) were contacted to verify ultimate patient placement, with follow-up through December 2010. Kaplan-Meier and Cox proportional hazards models were used to analyze postdischarge mortality. RESULTS: There were 1,352 consecutive admissions; 48% had an Injury Severity Score (ISS) greater than 15, and 12% died during admission. Of the patients who survived hospitalization, 51% were discharged to an SNF, 33% to home without assistance, 6% to home with assistance, and 5% to inpatient rehabilitation facilities. Within 1 year of injury, 44.6% of the patients were readmitted. The 1-year mortality for the overall cohort was 33%; for patients who were discharged alive, the 1-year mortality was 24%. After adjusting for confounders, patients discharged to an SNF had a threefold greater risk of 1-year mortality (hazard ratio, 2.82; 95% confidence interval, 1.86-4.28), compared with patients discharged home with no assistance. Of the patients discharged to an SNF, 48% died by the end of the follow-up period (mean, 28.2 months), and 61% of these patients died while residing at an SNF. CONCLUSION: GLFs in the elderly result in severe injury, high rate of readmissions, and increased mortality, both in-hospital and after discharge. Overall, only one third of the patients were discharged home to independent living. Future efforts should examine whether improvements in the quality of posthospital care affect both mortality and functional outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

BACKGROUND: In 2010, the National Highway Traffic Safety Administration standardized collision data collected by event data recorders, which may help determine appropriate emergency medical service (EMS) response. Previous models (e.g., General Motors ) predict severe injury (Injury Severity Score [ISS] > 15) using occupant demographics and collision data. Occupant information is not automatically available, and 12% of calls from advanced automatic collision notification providers are unanswered. To better inform EMS triage, our goal was to create a predictive model only using vehicle collision data. METHODS: Using the National Automotive Sampling System Crashworthiness Data System data set, we included front-seat occupants in late-model vehicles (2000 and later) in nonrollover and rollover crashes in years 2000 to 2010. Telematic (change in velocity, direction of force, seat belt use, vehicle type and curb weight, as well as multiple impact) and nontelematic variables (maximum intrusion, narrow impact, and passenger ejection) were included. Missing data were multiply imputed. The University of Washington model was tested to predict severe injury before application of guidelines (Step 0) and for occupants who did not meet Steps 1 and 2 criteria (Step 3) of the Centers for Disease Control and Prevention Field Triage Guidelines. A probability threshold of 20% was chosen in accordance with Centers for Disease Control and Prevention recommendations. RESULTS: There were 28,633 crashes, involving 33,956 vehicles and 52,033 occupants, of whom 9.9% had severe injury. At Step 0, the University of Washington model sensitivity was 40.0% and positive predictive value (PPV) was 20.7%. At Step 3, the sensitivity was 32.3 % and PPV was 10.1%. Model analysis excluding nontelematic variables decreased sensitivity and PPV. The sensitivity of the re-created General Motors model was 38.5% at Step 0 and 28.1% at Step 3. CONCLUSION: We designed a model using only vehicle collision data that was predictive of severe injury at collision notification and in the field and was comparable with an existing model. These models demonstrate the potential use of advanced automatic collision notification in planning EMS response. LEVEL OF EVIDENCE: Prognostic study, level II.

BACKGROUND: : Injuries to pedestrians struck by motor vehicles represent a significant public health hazard in large cities. The purpose of this study is to investigate the demographics of alcohol users who are struck by motor vehicles and to assess the effects of alcohol on pedestrian crossing patterns, medical management, and outcomes. METHODS: : Data were prospectively collected between December 2008 to September 2010 on all pedestrians who presented to a Level I trauma center after being struck by a motor vehicle. Variables were obtained by interviewing patients, scene witnesses, first responders, and medical records. RESULTS: : Pedestrians who used alcohol were less likely to cross the street in the crosswalk with the signal (22.6% vs. 64.7%) and more likely to cross either in the crosswalk against the signal (22.6% vs. 12.4%) or midblock (54.8% vs. 22.8%). Alcohol use was associated with more initial computed tomography imaging studies compared with no alcohol involvement. Alcohol use was associated with a higher Injury Severity Score (8.82 vs. 4.85; p < 0.001) and hospital length of stay (3.89 days vs. 1.82 days; p < 0.001) compared with those with no alcohol involvement. Patients who used alcohol had a lower average Glasgow Coma Scale score (13.80 vs. 14.76; p < 0.001) and a higher rate of head and neck, face, chest, abdomen, and extremity/pelvic girdle injuries (based on Abbreviated Injury Scale) than those with no alcohol involvement. CONCLUSION: : Alcohol use is a significant risk factor for pedestrians who are struck by motor vehicles. These patients are more likely to cross the street in an unsafe manner and sustain more serious injuries. Traffic safety and injury prevention programs must address irresponsible alcohol use by pedestrians

BACKGROUND: Bariatric operation is the most effective treatment for diabetes mellitus in the morbidly obese. The purpose of this study is to compare the rate of resolution of diabetes mellitus after three common laparoscopic bariatric procedures: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with or without duodenal switch (BPD/DS). STUDY DESIGN: All data were prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included preoperative age, body mass index, duration of diabetes, race, gender, operative time, length of stay, percent excess weight loss, oral hypoglycemic requirements, and insulin requirements. RESULTS: A total of 282 bariatric patients with diabetes mellitus were analyzed (218 LAGB, 53 RYGB, and 11 BPD/DS). Preoperative age (46 to 50 years), body mass index (46 to 50; calculated as kg/m(2)), race and gender breakdown, and baseline oral hypoglycemic (82% to 87%) and insulin requirements (18% to 28%) were comparable among the three groups (p = NS). Percent excess weight loss at 1, 2, and 3 years was: 43%, 50%, and 45% for LAGB; 66%, 68%, and 66% for RYGB; and 68%, 77%, and 82% for BPD/DS (p < 0.01 LAGB versus RYGB and LAGB versus BPD/DS at all time intervals). At 1 and 2 years, the proportion of patients requiring oral hypoglycemics postoperatively was 39% and 34% for LAGB; 22% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). At 1 and 2 years, the proportion of patients requiring insulin postoperatively was 14% and 18% for LAGB; 7% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). CONCLUSIONS: Despite the disparity in percent excess weight loss between LAGB, RYGB, and BPD/DS, the rate of resolution of diabetes mellitus is equivalent