Faculty Bibliography

We sought to investigate the effect of trauma center designation on organ donor outcomes during a 5-year period. A retrospective study of the southern California regional Organ Procurement Organization database comparing trauma centers (n = 25) versus nontrauma centers (n = 171) and Level I (n = 7) versus Level II (n = 18) trauma centers between 2004 and 2008 was performed. A total of 16,830 referrals were evaluated and 44 per cent were from trauma centers. When compared with nontrauma centers (n = 171), trauma centers (n = 25) had a higher percentage of medically suitable eligible deaths (29 vs 16%, P < 0.001), total eligible deaths (22 vs 12%, P < 0.001), and eligible donors (14 vs 7%, P < 0.001). Trauma Centers had a significantly higher number of organs procured per donor (4.0 +/- 1.6 vs 3.5 +/- 1.6, P < 0.001), organs transplanted per donor (OTPD) (3.6 +/- 1.8 vs 2.8 +/- 1.8, P < 0.001), and higher organ yield (per cent 4 or greater OTPD [48 vs 31%, P < 0.001]). No significant differences were found between Level I and Level II trauma centers. Trauma centers demonstrate significantly better organ donor outcomes compared with nontrauma centers. Factors responsible for improved outcomes at trauma centers should be evaluated, reproduced, and disseminated to nontrauma centers to alleviate the growing organ shortage crisis.

BACKGROUND: Systemic hypotension is a well documented predictor of increased mortality following traumatic brain injury (TBI). Hypotension is traditionally defined as systolic blood pressure (SBP)<90 mmHg. Recent evidence defines hypotension by a higher SBP in injured (non-TBI) trauma patients. We hypothesize that hypotension threshold requires a higher SBP in isolated moderate to severe TBI. PATIENTS AND METHODS: A retrospective database review of all adults (>/= 15 years) with isolated moderate to severe TBI (head abbreviated injury score (AIS)>/= 3, all other AIS /= 70 years. The main outcome variable was mortality, and the optimal definition of hypotension for each group was determined from the best fit model. Adjusted odds ratios (AOR) were then calculated to determine increased odds in mortality for the defined optimal SBP within each age group. RESULTS: A total of 15,733 patients were analysed. The optimal threshold of hypotension according to the best fit model was SBP of 110 mmHg for patients 15-49 years (AOR 1.98, CI 1.65-2.39, p<0.0001), 100 mmHg for patients 50-69 years (AOR 2.20, CI 1.46-3.31, p=0.0002), and 110 mmHg for patients >/= 70 years (AOR 1.92, CI 1.35-2.74, p=0.0003). CONCLUSIONS: Patients with isolated moderate to severe TBI should be considered hypotensive for SBP<110 mmHg. Further research should confirm this new definition of hypotension by correlation with indices of perfusion.

BACKGROUND: Conclusions from in vivo and in vitro studies suggest hypothermia may be protective in traumatic brain injury (TBI). Few studies evaluated the effect of admission temperature on outcomes. The purpose of this study is to examine the relationship between admission hypothermia and mortality in patients with isolated, blunt, moderate to severe TBI. METHODS: The Los Angeles Trauma Database was queried for all patients >/= 14 y of age with isolated, blunt, moderate to severe TBI (head abbreviated injury score (AIS) >/= 3, all other <3), admitted between 2005 and 2009. The study population was then stratified into two groups by admission temperature: hypothermic (35 degrees C). Demographic characteristics and outcomes were compared between groups. Logistic regression analysis was used to determine the relationship between admission hypothermia and mortality. RESULTS: A total of 1834 patients were analyzed and then stratified into two groups: hypothermic (n = 44) and normothermic (n = 1790). There was a significant difference noted in overall mortality (25% versus 7%), with the hypothermic group being four times more likely to succumb to their injuries. After adjusting for confounding factors, admission hypothermia was independently associated with increased mortality (AOR 2.5; 95% CI 1.1-6.3; P = 0.04). CONCLUSIONS: Although in-vivo and in-vitro studies demonstrate induced hypothermia may be protective in TBI, our study demonstrates that admission hypothermia was associated with increased mortality in isolated, blunt, moderate to severe TBI. Further prospective research is needed to elucidate the role of thermoregulation in patients sustaining TBI.

BACKGROUND: Recent evidence supports the beneficial effect of alcohol on patients with traumatic brain injury (TBI). Pneumonia is a known complication following TBI; thus, the purpose of this study was to evaluate the effects of alcohol on pneumonia rates following moderate to severe TBI. METHODS: From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients >/= 14 y of age with isolated moderate to severe TBI and admission serum alcohol levels. The incidence of pneumonia was compared between TBI patients with and without a positive blood alcohol concentration (BAC) level. The study population was then stratified into four BAC levels: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (>/= 230 mg/dL). Pneumonia rates were compared across these levels. RESULTS: A total of 3547 patients with isolated, moderate to severe TBI were evaluated. Nearly 66% tested positive for alcohol. The pneumonia rate was significantly lower in the TBI patients who tested positive for alcohol (2.5%) compared with those who tested negative (4.0%, P = 0.017). The pneumonia rate also decreased across increasing BAC levels (linear trend P = 0.03). After logistic regression analysis, a positive ethanol (ETOH) level was associated with a reduced incidence of pneumonia (AOR = 0.62; 95%CI: 0.41-0.93; P = 0.020). CONCLUSION: A positive serum alcohol level was associated with a significantly lower pneumonia rate in isolated, moderate to severe TBI patients. This may explain the observed mortality reduction in TBI patients who test positive for alcohol. Additional research is warranted to investigate the potential therapeutic implications of this association.

BACKGROUND:The organ supply shortage continues to be a public health care crisis, with nearly 20 people dying each day awaiting transplantation. Inability to obtain consent remains one of the major obstacles to converting potential donors into organ donors. We hypothesize that the presence of in-house coordinators (IHCs) from organ procurement organizations (OPOs) will improve organ donor conversion rates. METHODS:This retrospective review analyzed the effect of an IHC program on organ donation outcome. Referrals for possible organ donation from three IHC programs to regional organ procurement organizations were included. Data regarding organ donation demographics and outcomes were compared before (Pre-IHC) and after (Post-IHC) the establishment of an IHC program. The main outcome measures were conversion and family decline rates. The conversion rate was calculated as the number of actual donors divided by the number of eligible deaths and is represented as a percentage. The IHC functioned to assess for potential donors, ensure timely referrals, provide hospital staff education, assist with family consent and donor management, and provide family support. RESULTS:Post-IHC was associated with a significantly lower family decline rate (6% vs. 18%, p < 0.001), a significantly higher consent for research rate (8% vs. 0.4%, p < 0.001), and a significantly higher conversion rate (77% vs. 63%, p = 0.007) compared with Pre-IHC. In addition, a significant increase in referrals per day (0.35 vs. 0.27, p < 0.05) and organs transplanted per eligible death were noted Post-IHC. CONCLUSION/CONCLUSIONS:The presence of an IHC program significantly improves conversion rates for organ donation as well as organ yield. An IHC program should be considered as a viable option to bridge the gap between organ supply and organ demand.

OBJECTIVE:As the shortage of suitable organs for transplantation is especially pronounced among Hispanic Americans (HA), our objective was to determine whether a focused media campaign including culturally sensitive educational material on organ donation would positively influence organ donation awareness, perceptions, and beliefs, and increase the likelihood of organ donation in the HA community. METHODS:Cross-sectional telephone surveys were conducted before and after a media campaign in four Southern California neighborhoods with a high percentage of HA. Respondents, age ≥18 yr, were drawn randomly from lists of Hispanic surnames. Awareness, perception, and belief regarding organ donation and intent-to-donate were measured. The differences between the Pre- and Post-media surveys were analyzed. RESULTS:A total of 524 Pre-media and 528 Post-media subjects were evaluated. The Post-media surveys demonstrated improvements in: organ donation awareness (43% vs. 31%, p < 0.0001), the belief that donation is a social responsibility (54% vs. 45%, p = 0.008), and the belief that donation helps people (91% vs. 87%, p = 0.09). CONCLUSIONS:A media campaign emphasizing culturally sensitive educational material can significantly influence organ donation awareness and beliefs in HA.

BACKGROUND:Pregnant women, who have significantly elevated levels of estrogen and progesterone, might benefit from the neuroprotective effect of steroid hormones. METHODS:Pregnant patients were identified and compared with their nonpregnant counterparts with respect to demographics and outcome. RESULTS:Of the 18,800 female, moderate to severe TBI patients, 71 were pregnant. Similar mortalities were noted in pregnant and nonpregnant TBI patients (9.9% vs 9.3%, P = .84). Adjusting for confounding variables, pregnant TBI patients had a trend toward increased mortality (adjusted odds ratio [AOR] = 2.2; 95% confidence interval [CI], .9-5.1; P = .07). In patients aged 15 to 47 years (n = 8,854), similar mortalities were noted in pregnant and nonpregnant TBI patients (9.9% vs 6.8%, P = .34). After adjusting for risk factors, again there was a trend toward increased mortality in the pregnant TBI group (AOR = 2.0; 95% CI, .8-4.6; P = .12). CONCLUSIONS:Pregnant patients with moderate to severe TBI show no statistically significant difference in mortality compared with their nonpregnant counterparts.

BACKGROUND:Heparin use in surgical patients places them at increased risk for developing heparin-induced thrombocytopenia (HIT). The false positive rate of HIT using the current standard criteria is unknown in surgical ICU patients, who often have confounding factors that cause thrombocytopenia. STUDY DESIGN/METHODS:Surgical ICU patients, admitted over a 2-year period with a positive screening test for HIT (platelet factor [PF] 4 ≥ 0.4 optical density [OD]), were reviewed retrospectively at a single institution. Correlation of the Warkentin 4-T score and commercial heparin PF4 ELISA with serotonin releasing assay (SRA) was performed. Logistic regression was used to determine independent risk factors associated with the development of HIT. RESULTS:PF4 tests were requested in 643 patients based on a clinical suspicion of HIT. Of these, 104 patients had a PF4 result, an SRA value (%), and a 4-T score available. Twenty patients (19%) had true positive HIT, defined as a positive PF4 and positive SRA (SRA ≥ 20%). Eighty-four patients (81%) were false positive, defined as a positive PF4 and negative SRA. Five of 58 patients with Warkentin score of 0 to 3, and 6 of 14 patients with Warkentin score of 6 to 8 were HIT positive by SRA. CONCLUSIONS:In surgical ICU patients, clinical suspicion for HIT necessitates PF4 and SRA analysis. Testing for HIT or treatment with a direct thrombin inhibitor should not depend on the Warkentin 4-T score alone. Although a PF4 ≥ 0.4 OD is considered a positive screening test for HIT, a PF4 ≥ 2.0 OD is preferable in surgical ICU patients.