Faculty Bibliography

OBJECTIVE:To describe and evaluate trends of general surgery residency applicants, matriculants, and graduates over the last 13 years. SUMMARY OF BACKGROUND DATA/BACKGROUND:The application and matriculation rates of URMs to medical school has remained unchanged over the last three decades with Blacks and Hispanics representing 7.1% and 6.3% of matriculants, respectively. With each succession along the surgical career pathway, from medical school to residency to a faculty position, the percentage of URMs decreases. METHODS:The Electronic Residency Application Service to General Surgery Residency and the Graduate Medical Education Survey of residents completing general surgery residency were retrospectively analyzed (2005-2018). Data were stratified by race, descriptive statistics were performed, and time series were charted. RESULTS:From 2005 to 2018, there were 71,687 Electronic Residency Application Service applicants to general surgery residencies, 26,237 first year matriculants, and 24,893 general surgery residency graduates. Whites followed by Asians represented the highest percentage of applicants (n = 31,197, 43.5% and n = 16,602, 23%), matriculants (n = 16,395, 62.5% and n = 4768, 18.2%), and graduates (n = 15,239, 61% and n = 4804, 19%). For URMs, the applicants (n = 8603, 12%, P < 0.00001), matriculants (n = 2420, 9.2%, P = 0.0158), and graduates (n = 2508, 10%, P = 0.906) remained significantly low and unchanged, respectively, whereas the attrition was significantly higher (3.6%, P = 0.049) when compared to Whites (2.6%) and Asians (2.9%). CONCLUSION/CONCLUSIONS:Significant disparities in the application, matriculation, graduation, and attrition rates for general surgery residency exists for URMs. A call to action is needed to re-examine and improve existing recommendations/paradigms to increase the number of URMs in the surgery training pipeline.

BACKGROUND:While the incidence of geriatric trauma continues to increase, the management of high-grade blunt splenic injury (BSI) in the elderly remains controversial. Among this population, data evaluating survival rates following non-operative and operative management are inconsistent. We analyzed mortality risk in geriatric patients with high-grade BSI based on operative vs. non-operative management. METHODS:A retrospective analysis of the National Trauma Database identified patients with isolated, high-grade (AIS ≥ 3) BSI from 2014 to 2015. Patients were stratified into three groups: non-elderly (<65 years), elderly (65-79 years), and advanced age (80 years and older). Each age group was stratified into three management groups: non-operative (including embolization), initial operative management (OR within 24 h), and failed non-operative management. Patient characteristics and outcomes were compared. Multivariable logistic regression estimated association with mortality. RESULTS:5560 patients with isolated, high-grade BSI were identified. In the group that failed NOM, mortality was 2% in non-elderly patients, versus 22.2% in elderly patients and 50% in patients of advanced age (p < .01). In this group, patients over 80 years old spent an average of 6.5 days longer in the ICU vs. non-elderly patients (median 10.5 days, IQR [6.75, 19.5] vs. 4 days, IQR [3,6], p = 0.02). In patients with isolated, high grade BSI, age was independently associated with mortality (AOR 1.02; p < 0.01). Elderly patients who required surgery were over three times more likely to die (AOR 3.39; p < 0.01). Advanced age patients who required surgery were over eight times more likely to die (AOR 8.1; p < 0.01). CONCLUSIONS:For patients with BSI, age is independently associated with death in both operative and non-operative cases.

BACKGROUND:While mass-casualty incidents (MCIs) may have competing absolute definitions, a universally ac-cepted criterion is one that strains locally available resources. In the fall of 2017, a MCI occurred in New York and Bellevue Hospital received multiple injured patients within minutes; lessons learned included the need for a formal-ized, efficient patient and injury tracking system. Our objective was to create an organized MCI clinical tracking form for civilian trauma centers. METHODS:After the MCI, the notes of the surgeon responsible for directing patient triage were analyzed. A suc-cinct, organized template was created that allows MCI directors to track demographics, injuries, interventions, and other important information for multiple patients in a real-time fashion. This tool was piloted during a subsequent MCI. RESULTS:In late 2018, the hospital received six patients following another MCI. They arrived within a 4-minute window, with 5 patients being critically injured. Two emergent surgeries and angioembolizations were performed. The tool was used by the MCI director to prioritize and expedite care. All physicians agreed that the tool assisted in orga-nizing diagnostic and therapeutic triage. CONCLUSIONS:During MCIs, a streamlined patient tracking template assists with information recall and communica-tion between providers and may allow for expedited care.

BACKGROUND:Osteopenia is common in the elderly, increasing their risk of sustaining cervical fractures after ground level falls (GLFs). We sought to examine the incidence of blunt cerebrovascular injury (BCVI) and subsequent stroke in elderly GLF patients as compared with other higher injury mechanisms. MATERIALS AND METHODS/METHODS:The Trauma Quality Improvement Program database (2011-2016) was used to identify blunt trauma patients with isolated (other body region abbreviated injury scale <3) cervical spine (C1-C7) fractures. Patients were stratified into three groups: nonelderly patients (<65) with all mechanisms of injury, elderly patients (≥65) with GLF, and elderly patients with all other mechanism of injury. Multivariable logistic regression was used to determine predictors for BCVI, stroke, spinal cord injury, and acute kidney injury. RESULTS:Seventeen thousand six hundred twenty-eight patients with cervical spine injuries were identified. BCVI was highest in the <65 group (0.8%) and lowest in elderly patients with GLF (0.3%, P = 0.001). When controlling for other factors, elderly patients with GLF were less likely to sustain BCVI (adjusted odds ratio: 0.46, P = 0.03) but had comparable rates of stroke attributable to BCVI (18.2% versus 6.5%, P = 0.184) and comparable rate of acute kidney injury compared with elderly patients with other mechanism of injury. CONCLUSIONS:In elderly patients with isolated cervical spine fracture after GLF, BCVI occurs less frequently but is associated with a comparable rate of stroke as compared with other mechanisms. Low injury mechanism should not preclude BCVI screening in the presence of cervical spine fractures.

This study evaluated the safety of early anti-factor Xa assay-guided enoxaparin dosing for chemoprophylaxis in patients with TBI. We hypothesized that assay-guided chemoprophylaxis would be comparable in the risk of intracranial hemorrhage (ICH) progression to fixed dosing. An observational analysis of adult patients with blunt traumatic brain injury (TBI) was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group were treated with an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured four hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with a dose adjustment of ± 10 mg based on the assay result. The assay-guided group was compared with historical fixed-dose controls and to a TBI cohort from the most recent Trauma Quality Improvement Project dataset. Of 179 patients included in the study, 85 were in the assay-guided group and 94 were in the fixed-dose group. Compared with the fixed-dose group, the assay-guided group had a lower Glasgow Coma Score and higher Injury Severity Score. The proportion of severe (Abbreviated Injury Score, head ≥3) TBI, ICH progression, and venous thromboembolism rates were similar between all groups. The assay-guided and fixed-dose groups had chemoprophylaxis initiated earlier than the Trauma Quality Improvement Project group. The assay-guided group had the highest percentage of low molecular weight heparin use. Early initiation of enoxaparin anti-factor Xa assay-guided venous thromboembolism chemoprophylaxis has a comparable risk of ICH progression to fixed dosing in patients with TBI. These findings should be validated prospectively in a multicenter study.

BACKGROUND:We sought to evaluate the role of trauma center designation in the association of race and insurance status with disposition to rehabilitation centers among elderly patients with Traumatic Brain Injury (TBI). METHODS:The National Trauma Data Bank (2014-2015) was used to identify elderly (age ≥ 65) patients with isolated moderate to severe blunt TBI who survived to discharge. Race, insurance status, and outcomes were stratified by trauma center designation and compared. RESULTS:3,292 patients met the inclusion criteria. Black patients were 1.5 times less likely (AOR 0.64, p = 0.01) and Latino patients were 1.7 times less likely (AOR 0.58, p = 0 0.007) to be discharged to rehabilitation centers as compared with White patients. Asian patients at Level I hospitals were more likely to be discharged to rehabilitation centers if they had private vs. non-private insurance (42.9% versus 12.7%, p = 0.01). CONCLUSION/CONCLUSIONS:Black and Latino patients were less likely to be discharged to rehabilitation centers compared to White patients. The etiology of these disparities deserves further study.

BACKGROUND:While mass-casualty incidents (MCIs) may have competing absolute definitions, a universally accepted criterion is one that strains locally available resources. In the fall of 2017, a MCI occurred in New York and Bellevue Hospi-tal received multiple injured patients within minutes; lessons learned included the need for a formalized, efficient patient and injury tracking system. Our objective was to create an organized MCI clinical tracking form for civilian trauma centers. METHODS:After the MCI, the notes of the surgeon responsible for directing patient triage were analyzed. A suc-cinct, organized template was created that allows MCI directors to track demographics, injuries, interventions, and other important information for hmultiple patients in a real-time fashion. This tool was piloted during a subsequent MCI. RESULTS:In late 2018, the hospital received six patients following another MCI. They arrived within a 4-minute window, with 5 patients being critically injured. Two emergent surgeries and angioembolizations were performed. The tool was used by the MCI director to prioritize and expedite care. All physicians agreed that the tool assisted in organizing diagnostic and therapeutic triage. CONCLUSIONS:During MCIs, a streamlined patient tracking template assists with information recall and communica-tion between providers and may allow for expedited care.

BACKGROUND:The mangled extremity (ME) is a limb with a multisystem injury (soft tissue, bone, nerves, or vessels). We hypothesized that trauma patients who present with mangled lower extremities (ME) experience a higher rate of venous thromboembolism when matched against trauma patients of similar injury burden without ME. MATERIALS AND METHODS/METHODS:Data were abstracted from the Trauma Quality Improvement Program database from 2013 to 2016. Baseline comparisons were made between patients with and without ME. Propensity score matching with logistic regression modeling on the matched sample was performed controlling for patient gender, race, insurance status, age, injury severity score, Charlson comorbidity index, presence of significant other non-ME trauma, use of and time to prophylactic anticoagulation, placement of an inferior vena cava filter, and if immediate operative intervention was performed. RESULTS:A total of 1060 patients presented with an ME. Compared with other trauma patients, those with ME tended to be younger and male. They were more likely to receive prophylactic anticoagulation and an inferior vena cava filter. After propensity score matching, ME was statistically significantly associated with pulmonary embolism (PE) but not deep venous thrombosis (average treatment effect on the treated 1.7%, P = 0.04; and 1.4%, P = 0.22, respectively). These results were confirmed in a logistic regression on the matched sample (odds ratios 1.6, P = 0.11 for deep venous thrombosis, and odds ratio 3.2, P = 0.006 for PE). CONCLUSIONS:Patients with mangled lower extremities experience higher rates of PE. Based on these findings, institutions may consider evaluating their own VTE rates and chemoprophylaxis protocols in those with MEs.