Faculty Bibliography

Although recent evidence suggests a beneficial effect of alcohol for patients with traumatic brain injury (TBI), the level of alcohol that confers the protective effect is unknown. Our objective was to investigate the relationship between admission blood alcohol concentration (BAC) and outcomes in patients with isolated moderate to severe TBI. From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients >/=14 years of age with isolated moderate to severe TBI and admission serum alcohol levels. Patients were then stratified into four levels based on admission BAC: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (>/=230 mg/dL). Demographics, patient characteristics, and outcomes were compared across levels. In evaluating 3794 patients, the mortality rate decreased with increasing BAC levels (linear trend P < 0.0001). In determining the relationship between BAC and mortality, multivariable logistic regression analysis demonstrated a high BAC level was significantly protective (adjusted odds ratio 0.55; 95% confidence interval: 0.38-0.8; P = 0.002). In the largest study to date, a high (>/=230 mg/dL) admission BAC was independently associated with improved survival in patients with isolated moderate to severe TBI. Additional research is warranted to investigate the potential therapeutic implications.

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.

BACKGROUND: Early endotracheal intubation in patients sustaining moderate to severe traumatic brain injury (TBI) is considered the standard of care. Yet the benefit of pre-hospital intubation (PHI) in patients with TBI is questionable. The purpose of this study was to investigate the relationship between pre-hospital endotracheal intubation and mortality in patients with isolated moderate to severe TBI. METHODS: The Los Angeles County Trauma System Database was queried for all patients > 14 y of age with isolated moderate to severe TBI admitted between 2005 and 2009. The study population was then stratified into two groups: those patients requiring intubation in the field (PHI group) and those patients with delayed airway management (No-PHI group). Demographic characteristics and outcomes were compared between groups. Multivariate analysis was used to determine the relationship between pre-hospital endotracheal intubation and mortality. RESULTS: A total of 2549 patients were analyzed and then stratified into the two groups: PHI and No-PHI. There was a significant difference noted in overall mortality (90.2% versus 12.4%), with the PHI group being more likely to succumb to their injuries. After adjusting for possible confounding factors, multivariable logistic regression analysis demonstrated that PHI was independently associated with increased mortality (AOR 5, 95% CI: 1.7-13.7, P = 0.004). CONCLUSIONS: Pre-hospital endotracheal intubation in isolated, moderate to severe TBI patients is associated with a nearly 5-fold increase in mortality. Further prospective studies are required to establish guidelines for optimal pre-hospital management of this critically injured patient population.

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.

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:The Organ Donation Breakthrough Collaborative began in 2003 to address and alleviate the shortage of organs available for transplantation. This study investigated the patterns of organ donation by race to determine if the Collaborative had an impact on donation rates among ethnic minorities. STUDY DESIGN/METHODS:The following data from the Southern California regional organ procurement organization were reviewed between 2004 and 2008: age, race (Caucasian, African-American, Asian, Hispanic, and other), the numbers of eligible referrals for organ donation and actual donors, types of donors, consent rates, conversion rates, organs procured per donor (OPPD), and organs transplanted per donor (OTPD). Logistic regression was used to determine independent predictors of ≥4 OTPD. RESULTS:There were 1,776 actual donors out of 2,760 eligible deaths (conversion rate 64%). Hispanics demonstrated a significantly lower conversion rate than Caucasians (64% vs 77%, p < 0.001), but a considerably higher rate than African Americans (50%) and Asians (51%, p < 0.05 for both). There were no significant changes in conversion rates over time in any race. Age was a negative predictor (odds ratio [OR] 0.95), and trauma mechanism (OR 2.1) and standard criteria donor status (OR 2.5) were positive independent predictors of ≥4 OTPD. Race did not affect OTPD (all groups, p > 0.05). CONCLUSIONS:Conversion rates among all ethnic minorities were significantly lower than the rates observed in Caucasians. However, when controlling for other factors, race was not a significant risk factor for the number of organs transplanted per donor. The Collaborative has not had an identifiable effect on race conversion rates during the 5 years since its implementation. Further intervention is necessary to improve the conversion rate in ethnic minorities in Southern California.

Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. Multivariate logistic regression analysis was used to determine independent risk factors for mortality. Of 52,344 moderate to severe TBI patients, 41,711 (79.7%) were insured. Compared with the uninsured, insured TBI patients were older (46.1 +/- 22.4 vs. 37.3 +/- 16.3 years, P < 0.0001), more severely injured (ISS > or =16: 78.4% vs. 74.4%, P < 0.0001), had longer intensive care unit length of stay (6.0 +/- 9.4 vs. 5.1 +/- 7.6, P < 0.0001) and had higher mortality (9.3% vs. 8.0%, P < 0.0001). However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.

Animal studies routinely demonstrate an alcohol (ETOH) -mediated increase in survival after experimental traumatic brain injury (TBI). Recent clinical studies also suggest ETOH plays a neuroprotective role in moderate to severe TBI. We sought to investigate the relationship between ETOH and outcomes in patients with moderate to severe TBI using a countywide database. The Los Angeles County Trauma System database was queried for all adult (older than 14 years) patients with isolated moderate to severe TBI trauma (head Abbreviated Injury Score [AIS] 3 or greater, all other AIS 3 or less) who had ETOH levels measured on admission between 1998 and 2005. A total of 7304 patients were evaluated with 3219 (44.1%) patients testing positive for serum ETOH. ETOH-positive patients with TBI had a significantly lower mortality rate compared with ETOH negative patients (8.5 vs. 10.5%, P = 0.005). Even after logistic regression analysis, a positive ETOH was associated with reduced mortality (adjusted OR 0.82, 95% CI: 0.69-0.99, P = 0.035). Therefore, a positive serum ETOH level was independently associated with significantly improved survival in patients with isolated moderate to severe TBI. The neuroprotective role ETOH plays in TBI is in contrast to previous findings and deserves further attention as a potential therapeutic.

BACKGROUND:Traumatic brain injury (TBI) is the most common cause of death and disability in trauma patients, affecting over 1 million Americans per year. Minorities are at disproportionate risk for TBI, and they account for nearly half of all brain injury hospitalizations. Little is known regarding racial disparities in TBI patients. The objective of this study was to investigate the association of race on mortality in patients with moderate to severe isolated TBI. METHODS:The Los Angeles County Trauma System database, consisting of admissions from five Level I and eight Level II trauma centers, was queried for all patients with isolated moderate to severe TBI admitted between 1998 and 2005. Demographics and mortality were compared between races: Asian, African American, Hispanic, White, and Other. Multivariate logistic regression was used to determine the relationship between race and mortality. RESULTS:A total of 17,977 (23.8% female, 76.2% male) severe TBI patients were evaluated. Of this study population, 7.1% were Asian, 13.5% were African American, 42.3% were Hispanic, 32.5% were White, and 4.7% where classified as Other. Overall, Asians (adjusted Odds Ratio [AOR] 1.4; 95% CI: 1.14-1.71, P = 0.001) had a significantly higher risk in mortality when compared with Whites. Surprisingly, neither African Americans (AOR 1.02; 95% CI: 0.87-1.2, P = 0.82), nor Hispanics (AOR 1.00; 95% CI: 0.89-1.13, P > 0.9) were at increased risk of death compared to their White counterparts. CONCLUSION/CONCLUSIONS:This data supports the hypothesis that race may play a role in mortality in moderate to severe TBI. However, only Asians were at higher risk for death.