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: 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.

OBJECTIVE:To identify factors that contribute to intent to donate organs in Hispanic American individuals. DESIGN/METHODS:Cross-sectional telephone surveys. SETTING/METHODS:Four southern California neighborhoods with a high percentage of Hispanic American individuals. PATIENTS/METHODS:Respondents 18 years or older were drawn randomly from lists of Hispanic surnames. MAIN OUTCOME MEASURES/METHODS:Telephone surveys were conducted that measured demographic and socioeconomic factors, cultural factors, awareness and knowledge, and perception and belief regarding organ donation, as well as the intent to become an organ donor. Logistic regression was performed to identify independent contributing factors to intent to register for organ donation. RESULTS:Five hundred twenty-four telephone surveys were conducted over a 3-week period. Seventy-three percent of those surveyed were between the ages of 18 and 44 years and the sample was equally divided between men and women. The following independent risk factors contributed to intent to register: low acculturation (adjusted odds ratio [AOR], 0.39; 95% confidence interval [CI], 0.24-0.62; P < .001), religion (AOR, 0.33; 95% CI, 0.17-0.60; P < .001), perception that the wealthy are more likely to receive organs (AOR, 0.41; 95% CI, 0.25-0.65; P = .001), belief that donation disfigures the body and impacts the funeral (AOR, 0.45; 95% CI, 0.22-0.89; P = .02), and family influence (AOR, 2.02; 95% CI, 1.28-3.22; P = .004). CONCLUSIONS:Among Hispanic American individuals, low acculturation, religion, belief, and family influence affect the intent to register for organ donation. To improve organ donation, these risk factors should be considered using specific, effective educational programs.

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.

BACKGROUND:Increasing data indicate treatment with beta blockers might improve survival after traumatic brain injury (TBI); the optimal heart rate (HR) range for these patients is unknown. To guide treatment, admission HR in moderate to severe TBI patients was analyzed to determine if a specific range is associated with decreased mortality. METHODS:The Los Angeles County Trauma System Database, consisting of five Level I and 8 Level II trauma centers, was queried for all injured patients admitted between 1998 and 2005 (n = 147,788). Isolated moderate to severe TBI patients (head abbreviated injury score > or = 3) were then identified. Demographics and outcomes were compared at various admission HR subgroups (<50, 50-59, 60-69, 70-79, 80-89, 90-99, 100-109, > or =110). Logistic regression was then performed to determine predictors of mortality. RESULTS:After exclusions, a total of 11,977 isolated moderate to severe isolated TBI patients were analyzed, overall mortality was 11.5% with a trend toward lowest mortality at HR 80 to 89 (7.3%). Each HR subgroup had a significantly increased unadjusted odds ratio for mortality compared with HR 80 to 89, except HR 90 to 99 (OR 1.2, CI 1.0-1.5) and HR 100 to 109 (OR 1.2, CI 1.0-1.5). In multivariable logistic regression analysis, HR <50, 50-59, 60-69, and > or =110 were independent predictors for increased mortality compared with HR 80-89. CONCLUSION/CONCLUSIONS:After isolated moderate to severe TBI, HR <50, 50-59, 60-69, and > or =110 were independent predictors of increased mortality. HR outside the range 70-109 could serve as a marker for aggressive resuscitation. As mortality increased significantly with HR: <50 (AOR 4.70), 50-59 (AOR 2.21), and 60-69 (AOR 1.63), our findings recommend avoiding HR < 70 in patients with moderate to severe TBI.

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.

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.

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.

BACKGROUND:Male and female nervous systems respond differently to traumatic brain injury (TBI) and in vivo research relates this difference to neuroprotection from female sex hormones. Attempts to replicate female sex hormone-related neuroprotection in clinical studies have been unsuccessful. The objective of this study was to determine whether gender or menopausal status affects mortality in patients with moderate to severe TBI. METHODS:A retrospective review of all patients with isolated moderate to severe TBI was undertaken using data from the National Trauma Database version 6.2 (2000-2005). Isolated TBI was defined as head Abbreviated Injury Score >/=3 in patients without significant extracranial injuries (Abbreviated Injury Score <3 for other anatomic regions). Demographics, Injury Severity Score, and outcomes (mortality, intensive care unit and hospital length of stay, and complications) were compared. The population was stratified into age subgroups: 14 to 45 years (premenopausal), 46 to 55 years (perimenopausal), and older than 55 years (postmenopausal). Logistic regression analysis was used to determine the relationship among female gender, mortality, and development of complications after moderate to severe TBI. RESULTS:A total of 72,294 patients with moderate to severe TBI were evaluated. Females showed a significantly lower risk in both mortality (adjusted odds ratios [AOR], 0.82; 95% confidence intervals [CI], 0.77-0.87; p < 0.0001) and in developing any type of complications (AOR, 0.88; 95% CI, 0.84-0.93; p < 0.0001) than the male population after adjusting for differences in patient characteristics. After age stratification, perimenopausal women (46-55 years) and postmenopausal women (older than 55 years) showed a significantly lower risk in mortality (AOR, 0.76; 95% CI, 0.63-0.92; p < 0.0044 and AOR, 0.79; 95% CI, 0.73-0.86; p < 0.0001, respectively). There was no difference in mortality in premenopausal women compared with their male age-matched counterparts (AOR, 1.09; 95% CI, 0.99-1.21; p = 0.0917). CONCLUSIONS:Female gender is independently associated with reduced mortality and decreased complications after TBI. As peri- and postmenopausal women demonstrated improved survival, and premenopausal women did not, estrogen unlikely confers neuroprotection in women after TBI. Future TBI treatment may benefit with further research focused on why peri- and postmenopausal women show decreased mortality after TBI.

BACKGROUND:Emerging evidence suggests that male and female nervous systems respond differently to traumatic brain injury (TBI). The objective of this study was to examine outcomes between the sexes after TBI. PATIENTS AND METHODS/METHODS:A retrospective review of all severe TBI patients admitted between January and December 2005 was performed. Isolated severe TBI was defined as a head abbreviated injury score greater than 3 with an abbreviated injury score of 3 or less for other anatomic regions. The population was stratified into age subgroups (<14 y, 14-44 y, 45-54 y, and > or =55 y). Logistic regression was used to identify independent predictors of mortality. RESULTS:A total of 1,807 TBI patients were admitted. The mortality was significantly higher for women (43.2% vs 36.2%, P < .01) with an adjusted odds ratio of 1.4 (95% confidence interval, 1.1-1.9, P < .05). After stratification, only women age 55 and older had a significant difference in mortality (odds ratio, 1.71; 95% confidence interval, 1.11-2.62, P = .02). CONCLUSIONS:Female sex (particularly those age > or =55 y) is associated independently with higher mortality in isolated severe TBI. This increased mortality of postmenopausal women after isolated TBI may suggest a hormonal influence and warrants further investigation.