Faculty Bibliography

The objective of this study was to assess whether patients with comorbid psychiatric conditions admitted after traumatic injury require greater health-care resource utilization. The trauma registry of a Level 1 trauma center was used to identify all adult trauma patients presenting from 2012 to 2015. Patients with psychiatric needs, identified as having either an ICD-9 code corresponding to a psychiatric disorder or requiring inpatient psychiatric consultation, were compared with controls, using propensity score matching. Patients with psychiatric disorders were more than three times more likely to present with penetrating injuries (odds ratio [OR] 3.5, P < 0.005). They had longer length of hospital stay (median 5 [IQR 2.5-11] vs. three days [IQR 1-7], P < 0.01), were approximately 70 per cent more likely to require ICU-level care (OR 1.68, P = 0.08), and were 80 per cent less likely to be discharged home (OR 0.18, P < 0.005). Trauma patients with psychiatric illness or need consume greater health-care resources.

BACKGROUND:Firearm-related injuries cause significant morbidity and mortality in the United States (US), consuming resources and fueling political and public health discourse. Most analyses of firearm injuries are based on fatality statistics. Here, we describe the epidemiology of firearm injuries presenting to US emergency departments (EDs). METHODS:We performed a retrospective study of the Healthcare Cost and Utilization Program Nationwide Emergency Department Survey (NEDS) from 2009 to 2012. NEDS is the largest all-payer ED survey in the US containing approximately 30 million annual records. Results include survey-adjusted counts, proportions, means, and rates, and confidence intervals of age-stratified ED discharges for firearm injuries. RESULTS:There were 71,111 (se = 613) ED discharges for firearm injuries in 2009; the absolute number increased 3.9% (se = 1.2) to 75,559 (se = 610) in 2012. 18-to-44-year-olds accounted for the largest proportion of total injuries with 52,187 (se = 527) in 2009 and 56,644 (se = 528) in 2012-a 7.2% (se = 1.6) relative rate increase and an absolute increase of 3.3/100,000 (se = 0.7). Firearm injuries among children < 5-years-old increase 16%, and 19% among children 5-to-9-years-old. 136,112 (se = 761)-or 48.2%-of those injured were treated and discharged home without admission; 106,927 (se = 755) were admitted. Firearm deaths represented one-third of all trauma mortality. Three-quarters of those injured resided in neighborhoods with median incomes below $49,250. CONCLUSIONS:Firearm injuries increased from 2009 to 2012, driven by adults aged 18-to-44-years-old, and disproportionately impacting lower socioeconomic communities. Injuries also increased among young children. Firearm injuries remain a continued public health challenge, and a significant source of ED morbidity and mortality.

BACKGROUND:Between 1990 and 2003, there were 668 subway-related fatalities in New York City. However, subway-related trauma remains an understudied area of injury-related morbidity and mortality. OBJECTIVE:The objective of this study was to characterize the injuries and events leading up to the injuries of all patients admitted after subway-related trauma. METHODS:We conducted a retrospective case series of subway-related trauma at a Level I trauma center from 2001 to 2016. Descriptive epidemiology of patient demographics, incident details, injuries, and outcomes were analyzed. RESULTS:Over 15 years, 254 patients were admitted for subway-related trauma. The mean (standard error of the mean) age was 41 (1.0) years, 80% were male (95% confidence interval [CI] 74-84%) and median Injury Severity Score was 14 (interquartile range [IQR] 5-24). The overall case-fatality rate was 10% (95% CI 7-15%). The most common injuries were long-bone fractures, intracranial hemorrhage, and traumatic amputations. Median length of stay was 6 days (IQR 1-18 days). Thirty-seven percent of patients required surgical intervention. At the time of injury, 55% of patients (95% CI 49-61%) had a positive urine drug or alcohol screen, 16% (95% CI 12-21%) were attempting suicide, and 39% (95% CI 33-45%) had a history of psychiatric illness. CONCLUSIONS:Subway-related trauma is associated with a high case-fatality rate. Alcohol or drug intoxication and psychiatric illness can increase the risk of this type of injury.

BACKGROUND: Twenty-five percent of trauma patients are discharged to postacute care, indicating a loss of physical function and need for rehabilitation. The purpose of this study was to quantify the functional improvements in trauma patients discharged from inpatient rehabilitation facility (IRF) and identify predictors of improvement. MATERIALS AND METHODS: A retrospective cohort study of trauma patients aged >/= 18 years were admitted to an IRF after discharge from a level-1 trauma center. Data included demographics, injury characteristics, hospital, and IRF course. The functional independence measure (FIM) was used to measure change in physical and cognitive function. RESULTS: There were 245 patients with a mean age of 55.8 years and mean injury severity score (ISS) of 14.7. Fall was the leading mechanism of injury (45.7%). On IRF admission, 50.7% of patients required moderate or greater assistance. On discharge, the mean intraindividual change in FIM score was 29.9; 85.4% of the patients improved by >/=1 level of functioning. Before injury, 99.6% of patients were living at home, but only 56.0% were discharged home from the IRF, despite 81.8% requiring minimal assistance at most (23.5% to skilled nursing; 19.7% readmitted). Increasing age and lower ISS were associated with less FIM improvement, and increasing ISS was associated with increased FIM improvement. CONCLUSIONS: More than 80% of the trauma patients experienced meaningful functional improvements during IRF admission. However, only half were discharged home, and a quarter required further institutional care. Further research is needed to identify the additional impediments to return to preinjury functioning.

BACKGROUND: This study provides important updates to the epidemiology of pediatric trauma in the United States. METHODS: Age-specific epidemiologic analysis of the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, representing 2.4 million pediatric traumatic injury discharges in the US from 2000 to 2011. We present yearly data with overlying loess smoothing lines, proportions of common injuries and surgical procedures, and survey-adjusted logistic regression analysis. RESULTS: From 2000 to 2011 there was a 21.7% decline in US pediatric trauma injury inpatient discharges from 273.2 to 213.7 admissions per 100,000. Inpatient case-fatality decreased 5.5% from 1.26% (95% CI 1.05-1.47) to 1.19% (95% CI 1.01-1.38). Severe injuries accounted for 26.5% (se=0.11) of all discharges in 2000 increasing to 31.3% (se=0.13) in 2011. The most common injury mechanism across all age groups was motor vehicle crashes (MVCs), followed by assaults (15-19years), sports (10-14), falls (5-9) and burns (<5). The total injury-related, inflation-adjusted cost was $21.7 billion, increasing 56% during the study period. CONCLUSIONS: The overall rate of inpatient pediatric injury discharges across the United States has been declining. While injury severity is increasing in hospitalized patients, case-fatality rates are decreasing. MVCs remain a common source of all pediatric trauma. LEVELS OF EVIDENCE: Level III.

BACKGROUND: Despite reductions in youth pedestrian and bicyclist deaths over the past two decades, these injuries remain a substantial cause of morbidity and mortality for children and adolescents. There is a need for additional information on non-fatal pediatric pedestrian injuries and the role of traumatic brain injury (TBI), a leading cause of acquired disability. METHODS: Using a multi-year national sample of emergency department (ED) records, we estimated annual motorized-vehicle related pediatric pedestrian and bicyclist (i.e. pedalcyclist) injury rates by age and region. We modeled in-hospital fatality risk controlling for age, gender, injury severity, TBI, and trauma center status. RESULTS: ED visits for pediatric pedestrian injuries declined 19.3% (95% CI 16.8, 21.8) from 2006 to 2012, with the largest decreases in 5-to-9 year olds and 10-to-14 year olds. Case fatality rates also declined 14.0%. There was no significant change in bicyclist injury rates. TBI was implicated in 6.7% (95% CI 6.3, 7.1) of all pedestrian and bicyclist injuries and 55.5% (95% CI 27.9, 83.1) of fatalities. Pedestrian ED visits were more likely to be fatal than bicyclist injuries (aOR = 2.4, 95% CI 2.3, 2.6), with significant additive interaction between pedestrian status and TBI. CONCLUSIONS: TBI in young pedestrian ED patients was associated with a higher risk of mortality compared to cyclists. There is a role for concurrent clinical focus on TBI recovery alongside ongoing efforts to mitigate and prevent motor vehicle crashes with pedestrians and bicyclists. Differences between youth pedestrian and cycling injury trends merit further exploration and localized analyses, with respect to behavior patterns and interventions. ED data captures a substantially larger number of pediatric pedestrian injuries compared to crash reports and can play a role in those analyses.

BACKGROUND: Previous studies have reported that same-day laparoscopic cholecystectomy for acute cholecystitis is superior to delayed elective cholecystectomy. Although this practice is ideal, it requires significant hospital resources, particularly for an underprivileged inner-city population at a large, municipal hospital. We sought to evaluate the implementation of same-day laparoscopic cholecystectomy in a large, municipal hospital and assess the possible benefits of decreasing preoperative length of stay (LOS), particularly its effect on operative time and length of stay in patients with acute cholecystitis. MATERIALS AND METHODS: This was a retrospective chart review of patients treated for symptomatic gallstone disease between September 2012 and November 2013. Medical records were reviewed, and relevant data points were collected. Univariate and multivariate regressions were performed to assess the correlation between time to operation (<36 h [no delay] or >36 h [delay]) and the main outcomes (operative time and total length of stay). Inclusion criteria were patients age >/=18 y who underwent same-admission cholecystectomy and had a diagnosis of cholecystitis on pathology. Eighty-eight patients met all inclusion criteria. RESULTS: The mean (standard deviation) preoperative LOS was 76.2 (+/-48.6) h, the mean operative time was 2.3 (+/-1.1) h, and the mean postoperative LOS was 60.3 (+/-60.1) h. The average total LOS was 136 (+/-79.8) h. Operative times and postoperative LOS were similar for patients in the delay and no delay groups. Patients with >36 h wait before surgery had a total length of stay twice as long as patients with <36 h wait (152 versus 83.3 h; P = 0.0005). These findings remained significant when adjusted for age, sex, radiologic findings, number of preoperative tests, and pathology. CONCLUSIONS: Increased preoperative LOS is not associated with a significant increase in operative time. However, it was associated with significantly increased length of stay. Further analysis is needed to explore the potential cost savings of decreasing preoperative LOS.

Background: The anaesthetic dose causing neurotoxicity in animals has been evaluated, but the relationship between duration of volatile anaesthetic (VA) exposure and neurodevelopment in children remains unclear. Methods: Data were obtained from the Western Australian Pregnancy Cohort (Raine) Study, with language (Clinical Evaluation of Language Fundamentals: Receptive [CELF-R] and Expressive [CELF-E] and Total [CELF-T]) and cognition (Coloured Progressive Matrices [CPM]) assessed at age 10 yr. Medical records were reviewed, and children divided into quartiles based on total VA exposure duration before age three yr. The association between test score and exposure duration quartile was evaluated using linear regression, adjusting for patient characteristics and comorbidity. Results: Of 1622 children with available test scores, 148 had documented VA exposure and were split into the following quartiles: 25 to 35 to 60 min. Compared with unexposed children, CELF-T scores for children in the first and second quartiles did not differ, but those in the third and fourth quartiles had significantly lower scores ([3 rd quartile - Unexposed] -5.3; 95% confidence interval [CI], (-10.2 - -0.4), [4 th quartile - Unexposed] -6.2; 95% CI, (-11.6 - -0.9). CELF-E showed similar findings, but significant differences were not found in CELF-R or CPM for any quartile. Conclusions: Children with VA exposures 35 min had lower total and expressive language scores. It remains unclear if this is a dose-response relationship, or if children requiring longer exposures for longer surgeries have other clinical reasons for lower scores.

BACKGROUND: Animals exposed to anesthetics during specific age periods of brain development experience neurotoxicity, with neurodevelopmental changes subsequently observed during adulthood. The corresponding vulnerable age in children, however, is unknown. METHODS: An observational cohort study was performed using a longitudinal dataset constructed by linking individual-level Medicaid claims from Texas and New York from 1999 to 2010. This dataset was evaluated to determine whether the timing of exposure to anesthesia 28 days and 6 months and 1 year old and