Faculty Bibliography

BACKGROUND: While the efficacy of helmet use in the prevention of head injury is well described, helmet use as it relates to bicyclists' behaviors and hospital resource use following injury is less defined. The objective of this study was to compare the demographics, behaviors, hospital workups, and outcomes of bicyclists based on helmet use. METHODS: This study was a subset analysis of a 2.5-year prospective cohort study of vulnerable roadway users conducted at Bellevue Hospital Center, a New York City Level 1 trauma center. All bicyclists with known helmet status were included. Demographics, insurance type, traffic law compliance, alcohol use, Glasgow Coma Scale (GCS) score, initial imaging studies, Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), admission status, length of stay, disposition, and mortality were assessed. Information was obtained primarily from patients; witnesses and first responders provided additional information. RESULTS: Of 374 patients, 113 (30.2%) were wearing helmets. White bicyclists were more likely to wear helmets; black bicyclists were less likely (p = 0.037). Patients with private insurance were more likely to wear helmets, those with Medicaid or no insurance were less likely (p = 0.027). Helmeted bicyclists were more likely to ride with the flow of traffic (97.2%) and within bike lanes (83.7%) (p < 0.001 and p = 0.013, respectively). Nonhelmeted bicyclists were more likely to ride against traffic flow (p = 0.003). There were no statistically significant differences in mean GCS score, AIS score, and mean ISS for helmeted versus nonhelmeted bicyclists. Nonhelmeted patients were more likely to have head computed tomographic scans (p = 0.049) and to be admitted (p = 0.030). CONCLUSION: Helmet use is an indicator of safe riding practices, although most injured bicyclists do not wear them. In this study, helmet use was associated with lower likelihood of head CTs and admission, leading to less hospital resource use. Injured riders failing to wear helmets should be targeted for educational programs. LEVEL OF EVIDENCE: Epidemiologic study, level III.

HYPOTHESIS: Although investigators have reported that abdominal aortic aneurysm (AAA) repair is performed less frequently in black subjects than in white subjects, these findings may be explained by a lower prevalence of AAA disease among black subjects. We examine this assumption by determining the relative rate (RR) of elective AAA repair in black men vs white men after accounting for differences in disease prevalence. DESIGN: We used Medicare data from January 2001 to December 2003 to identify men 65 years and older undergoing elective or urgent AAA repair. We calculated the age-adjusted RR of repair in black men vs white men. We then used findings from the Aneurysm Detection and Management Veterans Affairs Cooperative Study to determine the ratio of screen-detected AAA prevalence among black men vs white men. Finally, we calculated prevalence-adjusted RRs of repair. SETTING: Medicare data study. PARTICIPANTS: Men 65 years and older undergoing elective or urgent AAA repair. MAIN OUTCOME MEASURE: Prevalence-adjusted RR of AAA repair in black men vs white men. RESULTS: The annual rate of elective AAA repair in black men was less than one-third that in white men (42.5 vs 147.8 per 100,000; RR, 0.29; 95% confidence interval [CI], 0.27-0.31). The disparity in urgent AAA repair was smaller, with black men undergoing repair at roughly half the rate of white men (26.1 vs 50.5 per 100,000; RR, 0.52; 95% CI, 0.48-0.56). The screen-detected disease prevalence of AAA among black men was less than half that among white men. Adjusting for this difference in prevalence diminished but did not erase the disparity in elective AAA repair (RR, 0.73; 95% CI, 0.68-0.77) and suggested that black men face a higher rate of urgent AAA repair (RR, 1.30; 95% CI, 1.21-1.41). CONCLUSIONS: Black men undergo elective AAA repair at a lower rate than white men even after accounting for their decreased disease burden. However, the prevalence-adjusted rate of urgent repair is higher among black men. Whether the lower frequency of elective procedures is responsible for the higher frequency of urgent procedures warrants further investigation

HYPOTHESIS: Efforts are under way to distribute hospital performance data directly to patients to inform their decisions about where to go for major surgery, but patients are not always involved in making the decision of where they will have surgery. DESIGN: Telephone interviews. PARTICIPANTS: Five hundred ten randomly selected Medicare patients who had undergone 1 of 5 elective high-risk operations approximately 3 years earlier: abdominal aneurysm repair (n = 103), heart valve replacement surgery (n = 96), or resections for bladder (n = 119), lung (n = 128), or stomach (n = 64) cancer. Main Outcome Measure Proportion of patients who responded that their physician was the main decision maker of where they would have surgery. RESULTS: Thirty-one percent of patients said their physician was the main decision maker about where the patient would have surgery (42% said they decided equally with their physician, 22% said they were the main decision maker, and 5% said their family helped make the decision for them). This proportion was similar across patient age, income, and educational attainment. Men were more likely to say the physician was the main decision maker (34% vs 24%; P = .02), as were patients in poor to fair health compared with those in good to excellent health (37% vs 28%; P = .05). The physician was significantly more likely to be the main decision maker for cardiovascular operations compared with cancer operations (39% vs 26%; P = .001). CONCLUSION: Although most patients participated in the decision of where they would have major surgery, one third said the decision was made mainly by their physician

Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality--with low-volume hospitals having the highest mortality. Medicare data (1992-2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume--a side effect that might increase mortality

OBJECTIVE: To review the evidence evaluating perioperative intranasal mupirocin for the prevention of surgical-site infections according to type of surgical procedure. DESIGN: Systematic review and meta-analysis of published clinical trials. SETTING: Studies included were either randomized clinical trial or prospective trials at a single institution that measured outcomes both before and after an institution-wide intervention (before-after trial). In all studies, intervention and control groups differed only by the use of perioperative intranasal mupirocin in the intervention group. PATIENTS: Patients undergoing general or nongeneral surgery (eg, cardiothoracic surgery, orthopedic surgery, and neurosurgery). MAIN OUTCOME MEASURE: Risk of surgical-site infection following perioperative intranasal mupirocin versus usual care. RESULTS: Three randomized and four before-after trials met the inclusion criteria. No reduction in surgical-site infection rate was seen in randomized general surgery trials (summary estimates: 8.4% in the mupirocin group and 8.1% in the control group; relative risk [RR], 1.04; 95% confidence interval [CI95], 0.81 to 1.33). In nongeneral surgery, the use of mupirocin was associated with a reduction in surgical-site infection in randomized trials (summary estimates: 6.0% in the mupirocin group and 7.6% in the control group; RR, 0.80; CI95, 0.58 to 1.10) and in before-after trials (summary estimates: 1.7% in the mupirocin group and 4.1% in the control group; RR, 0.40; CI95, 0.29 to 0.56). CONCLUSIONS: Perioperative intranasal mupirocin appears to decrease the incidence of surgical-site infection when used as prophylaxis in nongeneral surgery. Given its low risk and low cost, use of perioperative intranasal mupirocin should be considered in these settings

The response to injury is dependent on several factors, including the type and extent of the injury, genetics, and the environment. In the present study, the genetic contribution to sepsis was evaluated in a mouse model. Sepsis was induced in two inbred mouse strains, C57BL/6J (B6) and A/J, by cecal ligation and single puncture (CLP). Frequency of mortality was significantly higher in B6 than A/J mice from 36 to 132 h after CLP. Plasma TNF-alpha, IL-1beta, and IL-6 levels were similar in both strains after CLP. IL-10 plasma levels were significantly higher in B6 mice as opposed to A/J mice after 24 h of CLP. Similarly, hepatic myeloperoxidase activity, an index of polymorphonuclear leukocytes, was elevated in B6 mice as compared with A/J mice after 24 h of CLP. On the contrary, metallothionein mRNA levels were higher in A/J mice compared with B6 mice. Finally, leptin levels were also higher in A/J than B6 mice within 19 h of CLP. This study demonstrates a genetic contribution in the response to sepsis