Faculty Bibliography

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.

Aim: Our primary study objective was to identify risk factors for serious psychological distress (SPD) within the lesbian, gay, and bisexual (LGB) population, while accounting for the differences across these groups compared to heterosexual adults. We hypothesized that LGB adults had a higher risk for SPD compared to heterosexual adults, and that variation existed in SPD risk factors between LGB groups. Methods: National Health Interview Survey data collected from 2013 to 2018 were pooled to examine risk factors for SPD among gay men (n = 1752), bisexual men (n = 509), lesbian women (n = 1421), bisexual women (n = 1235), heterosexual men (n = 80,191) and heterosexual women (n = 97,909). A multivariate logistic regression model estimated SPD risk factors. Results: Bisexual women were at higher risk for SPD [adjusted odds ratio (AOR)= 2.5; 95% CI 1.8, 3.5]compared to heterosexual women. Bisexual (AOR = 3.8; 95% CI 1.9, 7.4) and gay men (AOR = 2.0; 95% CI 1.4, 3.0) were at increased risk for SPD compared to heterosexual men. Younger vs older adults were more likely to identify as bisexual or gay (18"�25�years vs 65�years and older identifying as gay men 17.0% vs 9.5%; bisexual men 33.4% vs 8.0%; lesbian 18.0% vs 8.6% and bisexual women 37.7% vs 3.5%). Gay men were more likely to live alone compared to other groups (34.5% vs 16.9% heterosexual men, 31.8% bisexual men, 17.6% heterosexual women, 20.7% lesbian, 19.7% bisexual women). Living alone increased risk for SPD among men (AOR = 2.2; 95%�CI 1.6, 3.0). Conclusion: Sexual minorities have increased mental health risks compared to heterosexual adults. Word Count: 248.

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.

BACKGROUND:Kidney transplant recipients have higher risk of infectious diseases due to their reliance on immunosuppression. During the current COVID-19 pandemic, some clinicians might have opted for less potent immunosuppressive agents to counterbalance the novel infectious risk. We conducted a nationwide study to characterize immunosuppression use and subsequent clinical outcomes during the first 5 months of COVID-19 pandemic in the United States. METHODS:Using data from the Scientific Registry of Transplant Recipients, we studied all kidney-only recipients in the United States from January 1, 2017, to March 12, 2020 ("prepandemic" era; n = 64 849) and from March 13, 2020, to July 31, 2020 ("pandemic" era; n = 5035). We compared the use of lymphocyte-depleting agents (versus basiliximab or no induction) and maintenance steroids (versus steroid avoidance/withdrawal) in the pandemic era compared with the prepandemic era. Then, we compared early posttransplant outcomes by immunosuppression regimen during the pandemic era. RESULTS:Recipients in the pandemic era were substantially less likely to receive lymphocyte-depleting induction agents compared with their prepandemic counterparts (aOR = 0.400.530.69); similar trends were found across subgroups of state-level COVID-19 incidence, donor type, and recipient age. However, lymphocyte-depleting induction agents were associated with decreased rejection during admission (aOR = 0.110.230.47) but not with increased mortality in the pandemic era (aHR = 0.130.471.66). On the other hand, the use of maintenance steroids versus early steroid withdrawal remained similar (aOR = 0.711.071.62). CONCLUSIONS:The use of lymphocyte-depleting induction agents has decreased in favor of basiliximab and no induction during the COVID-19 pandemic. However, this shift might have resulted in increases in rejection with no clear reductions in posttransplant mortality.

Persistent post-traumatic headache (PPTH) is often the most common injury post mild traumatic brain injury (mTBI), reported by 47%-95% of patients. Progressive muscle relaxation (PMR) has level A evidence in preventing migraine and tension headaches. However, research on this behavioral therapy for PPTH, let alone smartphone-delivered, is limited. We performed a single-arm study of prospective patients calling our Concussion Center between June 2017-July 2018. Inclusion criteria were that subjects had to meet ICHD-3 criteria for PPTH secondary to mTBI, have four or more headache days a month, be age 18-85 and 3-12 months post injury, own a smartphone and not tried headache behavioral therapy within the year. We recorded baseline headache and neuropsychiatric data. Using the RELAXaHEAD smartphone application, which has a headache diary and PMR audio files, participants were instructed to record headache symptoms and practice 20 minutes of PMR daily. There were three monthly follow-up assessments. There were 49 subjects enrolled. Basic demographics were: 33 (67%) female with mean age 40.1±14.6 [20,75]. Of the 49 subjects, 15 (31%) had pre-existing headaches. In 11 (22%) subjects, mTBI was sports-related. Subjects reported 17.7±9.3 [4,31] headache days in the month before enrollment, and 49 (100%) experienced over three concussion symptoms. Participants inputted data in the RELAXaHEAD app on average 18.3±12.0 days [0,31] the first month. Number of participants who did PMR over 4 times/week was 12 (24.5%) the first month, 9 (22.5 %) the second month, and 6 (15%) the third month. After three months, 17 (42.5 %) participants continued doing PMR. Participants cited time constraints, forgetfulness, application glitches and repetitiveness as obstacles to practicing PMR. It is feasible to get PPTH subjects to practice behavioral therapy through low-cost smartphone-based PMR two times weekly. Future work will assess efficacy and examine how to optimize barriers to PMR.

A variety of policies and practices have been implemented to increase participation in the National School Breakfast Program (SBP) and the impact of these initiatives on SBP participation is not known. The purpose of this study was to determine whether new SBP policies and practices implemented in North Carolina were associated with an improvement in SBP participation. A mixed modeling approach was used to assess longitudinal patterns of change in district-level and school-level SBP participation rates between 2007 and 2015. Most of the policy initiatives implemented in NC were associated with an increase in participation either at the school or district level.

Research Findings: Evidence suggests that teachers are effective at improving the social and emotional readiness of low-income children. However, few measures are available to assess teachers"™ use of specific social-emotional practices within their classrooms. This paper compares an observational measure of teachers"™ social-emotional practices, the Adapted Teacher Style Rating Scale (TSRS), to an instrument of general classroom climate within a randomized control trial, including 307 Head Start classrooms across the country. Results confirmed the expected underlying three-factor structure of the Adapted-TSRS across mixed-age and 4-year-old only Head Start classrooms. The measure was found to have good internal consistency, reliability, and acceptable concurrent correlations with other previously validated observational measures of classroom climate. Policy or Practice: The results support the usefulness and added value of a more specific observational measure of teachers"™ social-emotional practices.