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A disturbing trend: An analysis of the decline in surgical critical care (SCC) fellowship training of Black and Hispanic surgeons

Hambrecht, Amanda; Berry, Cherisse; DiMaggio, Charles; Chiu, William; Inaba, Kenji; Frangos, Spiros; Krowsoski, Leandra; Greene, Wendy Ricketts; Issa, Nabil; Pugh, Carla; Bukur, Marko
BACKGROUND:Underrepresented minorities in medicine (URiM) are disproportionally represented in surgery training programs. Rates of URiM applying to and completing General Surgery residency remain low. We hypothesized that the patterns of URiM disparities would persist into Surgical Critical Care (SCC) fellowship applicants, matriculants and graduates. METHODS:We performed a retrospective analysis of SCC applicants, matriculants and graduates from 2005-2020 using the Graduate Medical Education (GME) resident survey and analyzed applicant characteristics using the Surgical critical care and Acute care surgery Fellowship Application Service (SAFAS) from 2018-2020. The data were stratified by race/ethnicity and gender. Indicator variables were created for Asian, Hispanic, White and Black trainees. Yearly proportions for each race/ethnicity and gender categories completing or enrolling in a program were calculated and plotted over time with Loess smoothing lines and overlying 95% confidence bands. The yearly rate and statistical significance of change over time were tested with linear regression models with race/ethnicity and gender proportion as the dependent variables and year as the explanatory variable. RESULTS:From 2005-2020, there were a total of 2,481 graduates. Black men accounted for 4.7% of male graduates with a significant decline of 0.3% per year for the study period of those completing the fellowship (p = 0.02). Black women comprised 6.4% of female graduates and had a 0.6% decline each year (p < 0.01). A similar trend was seen with Hispanic men, who comprised 3.2% of male graduates and had a 0.3% annual decline (p = 0.02). White men had a significant increase in both matriculation to and graduation from SCC fellowships during the same interval. Similarly, Black and Hispanic applicants declined from 2019 to 2020, while the percentage of White applicants increased. CONCLUSIONS:Disparities in URiM representation remain omnipresent in surgery and extend from residency training to SCC fellowship. Efforts to enhance the recruitment and retention of URiM in SCC training are warranted. LEVEL OF EVIDENCE/METHODS:Level IV - Therapeutic/Care Management.
PMID: 35343928
ISSN: 2163-0763
CID: 5185002

Disparity in Transport of Critically Injured Patients to Trauma Centers: Analysis of the National Emergency Medical Services Information System (NEMSIS)

Escobar, Natalie; DiMaggio, Charles; Frangos, Spiros G; Winchell, Robert J; Bukur, Marko; Klein, Michael J; Krowsoski, Leandra; Tandon, Manish; Berry, Cherisse
BACKGROUND:Patient morbidity and mortality decrease when injured patients meeting CDC Field Triage Criteria (FTC) are transported by emergency medical services (EMS) directly to designated trauma centers (TCs). This study aimed to identify potential disparities in the transport of critically injured patients to TCs by EMS. STUDY DESIGN/METHODS:We identified all patients in the National EMS Information System (NEMSIS) database in the National Association of EMS State Officials East region from January 1, 2018, to December 31, 2019, with a final prehospital acuity of critical or emergent by EMS. The cohort was stratified into patients transported to TCs or non-TCs. Analyses consisted of descriptive epidemiology, comparisons, and multivariable logistic regression analysis to measure the association of demographic features, vital signs, and CDC FTC designation by EMS with transport to a TC. RESULTS:A total of 670,264 patients were identified as sustaining an injury, of which 94,250 (14%) were critically injured. Of those 94,250 critically injured, 56.0% (52,747) were transported to TCs. Among all critically injured women (n = 41,522), 50.4% were transported to TCs compared with 60.4% of critically injured men (n = 52,728, p < 0.001). In a multivariable logistic regression model, critically injured women were 19% less likely to be taken to a TC compared with critically injured men (OR 0.81, 95% CI 0.71-0.93, p = 0.003). CONCLUSIONS:Critically injured female patients are less likely to be transported to TCs when compared with their male counterparts. Performance improvement processes that assess EMS compliance with field triage guidelines should explicitly evaluate for sex-based disparities. Further studies are warranted.
PMID: 35703965
ISSN: 1879-1190
CID: 5236672

Acute Appendicitis During The COVID-19 Pandemic: A Multicenter, Retrospective Analysis From The US Epicenter

Tamirian, Richard; Klein, Michael; Chui, Patricia; Park, Julia; Frangos, Spiros; Shah, Paresh; Malino, Cris M K
BACKGROUND:Acute appendicitis (AA) is the most common surgical emergency, with a relatively stable yearly incidence. During the first wave of the COVID-19 pandemic, as New York City (NYC) emerged as the US epicenter, hospitals saw a marked reduction in patients presenting with non-COVID-related diseases. The objective of this study was to characterize the effects of the pandemic on the incidence, presentation, and management of AA. METHODS:A retrospective analysis of patients with AA who presented to two academic medical centers during the NYC COVID peak (March 22nd-May 31st, 2020) was performed. This group was compared to a control cohort presenting during the same period in 2019. Primary outcomes included the incidence of AA, complicated disease, and management. Secondary outcomes included duration of symptoms, hospital length of stay, and complication rates. Statistical analyses were performed using Mann-Whitney U, Chi-square, and Fisher's exact tests. RESULTS:< .02). Hospital length of stay and complication rates were similar between years. DISCUSSION/CONCLUSIONS:Significantly fewer AA patients presented during the initial phase of the pandemic. Patients presented later, which may have contributed to a higher proportion of complicated disease. Surgeons were also more likely to treat uncomplicated AA nonoperatively than they were prior. Further research is needed to understand the long-term consequences of these changes.
PMID: 35599614
ISSN: 1555-9823
CID: 5236402

Examination of Intersectionality and the Pipeline for Black Academic Surgeons

Keshinro, Ajaratu; Butler, Paris; Fayanju, Oluwadamilola; Khabele, Dineo; Newman, Erika; Greene, Wendy; Ude Welcome, Akuezunkpa; Joseph, Kathie-Ann; Stallion, Anthony; Backhus, Leah; Frangos, Spiros; DiMaggio, Charles; Berman, Russell; Hasson, Rian; Rodriguez, Luz Maria; Stain, Steven; Bukur, Marko; Klein, Michael J; Henry-Tillman, Ronda; Barry, Linda; Oseni, Tawakalitu; Martin, Colin; Johnson-Mann, Crystal; Smith, Randi; Karpeh, Martin; White, Cassandra; Turner, Patricia; Pugh, Carla; Hayes-Jordan, Andrea; Berry, Cherisse
Importance/UNASSIGNED:The lack of underrepresented in medicine physicians within US academic surgery continues, with Black surgeons representing a disproportionately low number. Objective/UNASSIGNED:To evaluate the trend of general surgery residency application, matriculation, and graduation rates for Black trainees compared with their racial and ethnic counterparts over time. Design, Setting, and Participants/UNASSIGNED:In this nationwide multicenter study, data from the Electronic Residency Application Service (ERAS) for the general surgery residency match and Graduate Medical Education (GME) surveys of graduating general surgery residents were retrospectively reviewed and stratified by race, ethnicity, and sex. Analyses consisted of descriptive statistics, time series plots, and simple linear regression for the rate of change over time. Medical students and general surgery residency trainees of Asian, Black, Hispanic or Latino of Spanish origin, White, and other races were included. Data for non-US citizens or nonpermanent residents were excluded. Data were collected from 2005 to 2018, and data were analyzed in March 2021. Main Outcomes and Measures/UNASSIGNED:Primary outcomes included the rates of application, matriculation, and graduation from general surgery residency programs. Results/UNASSIGNED:Over the study period, there were 71 687 applicants, 26 237 first-year matriculants, and 24 893 graduates. Of 71 687 applicants, 24 618 (34.3%) were women, 16 602 (23.2%) were Asian, 5968 (8.3%) were Black, 2455 (3.4%) were Latino, and 31 197 (43.5%) were White. Women applicants and graduates increased from 29.4% (1178 of 4003) to 37.1% (2293 of 6181) and 23.5% (463 of 1967) to 33.5% (719 of 2147), respectively. When stratified by race and ethnicity, applications from Black women increased from 2.2% (87 of 4003) to 3.5% (215 of 6181) (P < .001) while applications from Black men remained unchanged (3.7% [150 of 4003] to 4.6% [284 of 6181]). While the matriculation rate for Black women remained unchanged (2.4% [46 of 1919] to 2.3% [52 of 2264]), the matriculation rate for Black men significantly decreased (3.0% [57 of 1919] to 2.4% [54 of 2264]; P = .04). Among Black graduates, there was a significant decline in graduation for men (4.3% [85 of 1967] to 2.7% [57 of 2147]; P = .03) with the rate among women remaining unchanged (1.7% [33 of 1967] to 2.2% [47 of 2147]). Conclusions and Relevance/UNASSIGNED:Findings of this study show that the underrepresentation of Black physicians at every stage in surgical training pipeline persists. Black men are especially affected. Identifying factors that address intersectionality and contribute to the successful recruitment and retention of Black trainees in general surgery residency is critical for achieving racial and ethnic as well as gender equity.
PMID: 35138327
ISSN: 2168-6262
CID: 5171692

Percutaneous Dilational Tracheostomy at the Epicenter of the SARS-CoV-2 Pandemic: Impact on Critical Care Resource Utilization and Early Outcomes

Krowsoski, Leandra; Medina, Benjamin D; DiMaggio, Charles; Hong, Charles; Moore, Samantha; Straznitskas, Andrew; Rogers, Charmel; Mukherjee, Vikramjit; Uppal, Amit; Frangos, Spiros; Bukur, Marko
BACKGROUND:The COVID-19 pandemic overwhelmed New York City hospitals early in the pandemic. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. This study evaluates the impact of percutaneous dilational tracheostomy (PDT) in COVID+ patients on critical care capacity. METHODS:This is a single-institution prospective case series of mechanically ventilated COVID-19 patients undergoing PDT from April 1 to June 4, 2020 at a public tertiary care center. RESULTS:Fifty-five patients met PDT criteria and underwent PDT at a median of 13 days (IQR 10, 18) from intubation. Patient characteristics are found in Table 1. Intravenous midazolam, fentanyl, and cisatracurium equivalents were significantly reduced 48 hours post-PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 (IQR 4, 14) and 12 (IQR 8, 17) days, respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care (Figure 1). Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). All operators tested negative for COVID-19 during the study period. CONCLUSION/CONCLUSIONS:These findings suggest COVID-19 patients undergoing tracheostomy within the standard time frame can improve critical care capacity in areas strained by the pandemic with low risk to operators. Long-term outcomes after PDT deserve further study.
PMID: 34766508
ISSN: 1555-9823
CID: 5050782

The role of alcohol and other drugs on emergency department traumatic injury mortality in the United States

DiMaggio, Charles J; Avraham, Jacob B; Frangos, Spiros G; Keyes, Katherine
BACKGROUND:Alcohol and other drugs (AOD) increase the risk of traumatic injury occurring, but data suggest a protective benefit in preventing trauma-related mortality. The objective of this study is to describe the epidemiology of AOD-related traumatic injury in the US over a recent 7 year period and assess the interaction of traumatic injury and AOD on pre-admission fatality on both an additive scale using incidence contrasts and on a statistical multiplicative scale using survey-adjusted logistic regression. METHODS:Using the National Emergency Department Sample (NEDS), we describe the epidemiology of alcohol and substance-related emergency department traumatic injury over a recent period. AOD-related injury was assessed using survey-adjusted counts and means. Ratio estimates and differences were calculated using simulations based on survey-adjusted counts and standard errors. Differences in trends over time were evaluated by comparing the slopes of linear regression equations with year as the predictor variable. RESULTS:Alcohol and substance-related emergency department injury discharges increased 9.8 % during the study period. There was a statistically significant interaction between traumatic injury death and AOD on both an additive scale and multiplicative scale. (Odds Ratio for interaction term = 1.76, 95 % CI = 1.53, 2.03). CONCLUSIONS:AOD use does not provide a protective benefit in the setting of trauma, but rather is an important contributor to traumatic injury mortality.
PMID: 34049099
ISSN: 1879-0046
CID: 4888482

Race and Insurance Status are Associated With Different Management Strategies After Thoracic Trauma

Rebollo Salazar, Daniela; Velez-Rosborough, Anna; DiMaggio, Charles; Krowsoski, Leandra; Klein, Michael; Berry, Cherisse; Tandon, Manish; Frangos, Spiros; Bukur, Marko
INTRODUCTION/BACKGROUND:Health-care disparities based on race and socioeconomic status among trauma patients are well-documented. However, the influence of these factors on the management of rib fractures following thoracic trauma is unknown. The aim of this study is to describe the association of race and insurance status on management and outcomes in patients who sustain rib fractures. METHODS:The Trauma Quality Improvement Program database was used to identify adult patients who presented with rib fractures between 2015 and 2016. Patient demographics, injury severity, procedures performed, and outcomes were evaluated. Multivariate logistic regression analysis was used to determine the effect of race and insurance status on mortality and the likelihood of rib fixation surgery and epidural analgesia for pain management. RESULTS:A total of 95,227 patients were identified. Of these, 2923 (3.1%) underwent rib fixation. Compared to White patients, Asians (AOR: 0.57, P = 0.001), Blacks or African-Americans (AA) (AOR: 0.70, P < 0.001), and Hispanics/Latinos (HL) (AOR: 0.78, P < 0.001) were less likely to undergo rib fixation surgery. AA patients (AOR: 0.67, P = 0.004), other non-Whites (ONW) (AOR: 0.61, P = 0.001), and HL (AOR 0.65, P = 0.006) were less likely to receive epidural analgesia. Compared to privately insured patients, mortality was higher in uninsured patients (AOR: 1.72, P < 0.001), Medicare patients (AOR: 1.80, P < 0.001), and patients with other non-private insurance (AOR: 1.23, P < 0.001). CONCLUSIONS:Non-White race is associated with a decreased likelihood of rib fixation and/or epidural placement, while underinsurance is associated with higher mortality in patients with thoracic trauma. Prospective efforts to examine the socioeconomic disparities within this population are warranted.
PMID: 33401122
ISSN: 1095-8673
CID: 4738802

Temporal Changes in Reboa Utilization Practices are Associated with Increased Survival: An Analysis of the Aorta Registry

Bukur, Marko; Warnack, Elizabeth; DiMaggio, Charles; Frangos, Spiros; Morrison, Jonathan J; Scalea, Thomas M; Moore, Laura J; Podbielski, Jeanette; Inaba, Kenji; Kauvar, David; Cannon, Jeremy W; Seamon, Mark J; Spalding, M Chance; Fox, Charles; DuBose, Joseph J
BACKGROUND:Aortic occlusion (AO) is utilized for patients in extremis, with resuscitative endovascular balloon occlusion of the aorta (REBOA) use increasing. Our objective was to examine changes in AO practices and outcomes over time. The primary outcome was the temporal variation in AO mortality, while secondary outcomes included changes in technique, utilization, and complications. STUDY DESIGN/METHODS:This study examined the AORTA registry over a 5-year period (2014-2018). AO outcomes and utilization were analyzed using year of procedure as an independent variable. A multivariable model adjusting for year of procedure, signs of life (SOL), SBP at AO initiation, operator level, timing of AO, and hemodynamic response to AO was created to analyze AO mortality. RESULTS:1458 AO were included. Mean age (39.1 ± 16.7) and Median ISS (34[25,49]) were comparable between REBOA and Open AO. Open AO patients were more likely: male (84% vs. 77%, p = 0.001), s/p penetrating trauma (61% vs. 19%, p < 0.001), and arrived without SOL (60% vs. 40%, p = 0.001). REBOA use increased significantly and adjusted mortality decreased 22%/year while open AO survival was unchanged. REBOA initiation SBP increased significantly over the study period (52.2 vs. 65, p = 0.04). Compared with patients undergoing AO with CPR, each decile increase in SBP improved survival 12% (AOR 1.12, adj p = 0.001). The use of 7F REBOA (2.9% to 54.8%) and Zone III deployment increased significantly (14.7% vs 40.6%), with Zone III placement having decreased associated mortality (AOR 0.33, adj p = 0.001). Overall REBOA complication rate was 4.5% and did not increase over time (p = 0.575). CONCLUSIONS:REBOA survival has increased significantly while open AO survival remained unchanged. This may be related to lower thresholds for REBOA insertion at higher blood pressures, increased operator experience and improved catheter technology leading to earlier deployment.
PMID: 32842023
ISSN: 1540-0514
CID: 4574242

Injuries associated with electric-powered bikes and scooters: analysis of US consumer product data

DiMaggio, Charles J; Bukur, Marko; Wall, Stephen P; Frangos, Spiros G; Wen, Andy Y
BACKGROUND:Powered, two-wheeled transportation devices like electric bicycles (E-bikes) and scooters are increasingly popular, but little is known about their relative injury risk compared to pedal operated bicycles. METHODS:Descriptive and comparative analysis of injury patterns and trends associated with E-bikes, powered scooters and pedal bicycles from 2000 to 2017 using the US National Electronic Injury Surveillance System. RESULTS:While persons injured using E-bikes were more likely to suffer internal injuries (17.1%; 95% CI 5.6 to 28.6) and require hospital admission (OR=2.8, 95% CI 1.3 to 6.1), powered scooter injuries were nearly three times more likely to result in a diagnosis of concussion (3% of scooter injuries vs 0.5% of E-bike injuries). E-bike-related injuries were also more than three times more likely to involve a collision with a pedestrian than either pedal bicycles (OR=3.3, 95% CI 0.5 to 23.6) or powered scooters (OR=3.3, 95% CI 0.3 to 32.9), but there was no evidence that powered scooters were more likely than bicycles to be involved in a collision with a pedestrian (OR=1.0, 95% CI 0.3 to 3.1). While population-based rates of pedal bicycle-related injuries have been decreasing, particularly among children, reported E-bike injuries have been increasing dramatically particularly among older persons. CONCLUSIONS:E-bike and powered scooter use and injury patterns differ from more traditional pedal operated bicycles. Efforts to address injury prevention and control are warranted, and further studies examining demographics and hospital resource utilisation are necessary.
PMID: 31712276
ISSN: 1475-5785
CID: 4185102

Response Regarding: "Elderly Patients With Cervical Spine Fractures After Ground Level Falls are at Risk for Blunt Cerebrovascular Injury" [Letter]

Gorman, Elizabeth; DiMaggio, Charles; Frangos, Spiros; Klein, Michael; Berry, Cherisse; Bukur, Marko
PMID: 32838972
ISSN: 1095-8673
CID: 4574232