Faculty Bibliography

INTRODUCTION:Tracheostomy in patients with COVID-19 is a controversial and difficult clinical decision. We hypothesized that a recently validated COVID-19 Severity Score (CSS) would be associated with survival in patients considered for tracheostomy. METHODS:We reviewed 77 mechanically ventilated COVID-19 patients evaluated for decision for percutaneous dilational tracheostomy (PDT) from March to June 2020 at a public tertiary care center. Decision for PDT was based on clinical judgment of the screening surgeons. The CSS was retrospectively calculated using mean biomarker values from admission to time of PDT consult. Our primary outcome was survival to discharge, and all patient charts were reviewed through August 31, 2021. ROC curve and Youden index were used to estimate an optimal cut-point for survival. RESULTS:The mean CSS for 42 survivors significantly differed from that of 35 nonsurvivors (CSS 52 versus 66, P = 0.003). The Youden index returned an optimal CSS of 55 (95% confidence interval 43-72), which was associated with a sensitivity of 0.8 and a specificity of 0.6. The median CSS was 40 (interquartile range 27, 49) in the lower CSS (<55) group and 72 (interquartile range 66, 93) in the high CSS (≥55 group). Eighty-seven percent of lower CSS patients underwent PDT, with 74% survival, whereas 61% of high CSS patients underwent PDT, with only 41% surviving. Patients with high CSS had 77% lower odds of survival (odds ratio = 0.2, 95% confidence interval 0.1-0.7). CONCLUSIONS:Higher CSS was associated with decreased survival in patients evaluated for PDT, with a score ≥55 predictive of mortality. The novel CSS may be a useful adjunct in determining which COVID-19 patients will benefit from tracheostomy. Further prospective validation of this tool is warranted.

This study aims to assess the relationship between county-level fatal crash injuries and road environmental characteristics at all times of the day and during the rush and non-rush hour periods. We merged eleven-year (2010 - 2020) data from the Fatality Analysis Reporting System. The outcome variable was the county-level fatal crash injury counts. The predictor variables were measures of road types, junction types and work zone, and weather types. We tested the predictiveness of two nested negative binomial models and adjudged that a nested spatial negative binomial regression model outperformed the non-spatial negative binomial model. The median county crash mortality rates at all times of the day and during the rush and non-rush hour periods were 18.4, 7.7, and 10.4 per 100,000 population, respectively. Fatal crash injury rate ratios were significantly elevated on interstates and highways at all times of the day "“ rush and non-rush hour periods inclusive. Intersections, driveways, and ramps on highways were associated with elevated fatal crash injury rate ratios. Clusters of high fatal crash injury rates were observed in counties located in Montana, Nevada, Colorado, Kansas, New Mexico, Oklahoma, Texas, Arkansas, Mississippi, Alabama, Georgia, and Nevada. The built and natural road environment factors are associated with county-level fatal crash injuries during the rush and non-rush hour periods. Understanding the association of road environment characteristics and the cluster distribution of fatal crash injuries may inform areas in need of focused intervention.

BACKGROUND:Increased time to surgery (TTS) is associated with decreased survival in patients with breast cancer. In early 2020, elective surgeries were canceled to preserve resources for patients with coronavirus disease 2019 (COVID-19). This study attempts to measure the effect of mandated operating room shutdowns on TTS in patients with breast cancer. PATIENTS AND METHODS/METHODS:This multicenter retrospective study compares 51 patients diagnosed with breast cancer at four public hospitals from January to June 2020 with 353 patients diagnosed from January 2017 to June 2018. Demographics, tumor characteristics, treatment regimens, and TTS for patients were statistically compared using parametric, nonparametric, and Cox proportional hazards regression modeling. RESULTS:Across all centers, there was a non-statistically significant increase in median TTS from 59 days in the pre-COVID period to 65 days during COVID (p = 0.9). There was, however, meaningful variation across centers. At center A, the median TTS decreased from 57 to 51 days, center C's TTS decreased from 83 to 64 days, and in center D, TTS increased from 42 to 129 days. In a multivariable Cox proportional hazards model for the pre-COVID versus COVID period effect on TTS, center was an important confounding variable, with notable differences for centers C and D compared with the referent category of center A (p = 0.04, p = 0.006). CONCLUSION/CONCLUSIONS:Data suggest that, while mandated operating room shutdowns did not result in an overall statistically significant delay in TTS, there were important differences between centers, indicating that, even in a unified multicenter public hospital system, COVID-19 may have resulted in delayed and potentially disparate care.

BACKGROUND:Deaths at the crash scene (DAS) are crash deaths that occur within minutes after a crash. Rapid crash responses may reduce the occurrence of DAS. OBJECTIVES/OBJECTIVE:This study aims to assess the association of crash response time and DAS during the rush and nonrush hour periods by rurality/urbanicity. METHOD/METHODS:This single-year cross-sectional study used the 2019 National Emergency Medical Services (EMS) Information System. The outcome variable was DAS. The predictor variables were crash response measures: EMS Chute Initiation Time (ECIT) and EMS Travel Time (ETT). Age, gender, substance use, region of the body injured, and the revised trauma score were used as potential confounders. Logistic regression was used to assess the unadjusted and adjusted odds of DAS. RESULTS:A total of 654,675 persons were involved in EMS-activated road crash events, with 49.6% of the population exposed to crash events during the rush hour period. A total of 2,051 persons died at the crash scene. Compared to the baseline of less than 1 minute, ECIT ranging from 1 to 5 minutes was significantly associated with 58% (95% CI: 1.45-1.73) increased odds of DAS. Also, when compared to the baseline of less than 9 minutes, ETT ranging between 9 and 18 minutes was associated with 34% (95% CI: 1.22-1.47) increased odds of DAS. These patterns were consistent during the rush and nonrush hour periods and across rural and urban regions. CONCLUSION/CONCLUSIONS:Reducing crash response times may reduce the occurrence of DAS.

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.

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.

OBJECTIVE:The aim of this study was to assess occupational circumstances associated with adverse mental health among health care workers during the COVID-19 pandemic. METHODS:A cross-sectional study examined responses to an on-line survey conducted among 2076 licensed health care workers during the first pandemic peak. Mental health (depression, anxiety, stress, and anger) was examined as a multivariate outcome for association with COVID-related occupational experiences. RESULTS:Odds of negative mental health were increased among those who worked directly with patients while sick themselves (adjusted odds ratio, 2.29; 95% confidence interval, 1.71-3.08) and were independently associated with working more hours than usual in the past 2 weeks, having family/friends who died due to COVID-19, having COVID-19 symptoms, and facing insufficiencies in personal protective equipment/other shortages. CONCLUSIONS:Occupational circumstances were associated with adverse mental health outcomes among health care workers during the COVID-19 pandemic, and some are potentially modifiable.

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.

BACKGROUND:Understanding how substance use is associated with severe crash injuries may inform emergency care preparedness. OBJECTIVES/OBJECTIVE:This study aims to assess the association of substance use and crash injury severity at all times of the day and during rush (6-9 AM; 3-7 PM) and non-rush-hours. Further, this study assesses the probabilities of occurrence of low acuity, emergent, and critical injuries associated with substance use. METHODS:Crash data were extracted from the 2019 National Emergency Medical Services Information System. The outcome variable was non-fatal crash injury, assessed on an ordinal scale: critical, emergent, low acuity. The predictor variable was the presence of substance use (alcohol or illicit drugs). Age, gender, injured part, revised trauma score, the location of the crash, the road user type, and the geographical region were included as potential confounders. Partially proportional ordinal logistic regression was used to assess the unadjusted and adjusted odds of critical and emergent injuries compared to low acuity injury. RESULTS:Substance use was associated with approximately two-fold adjusted odds of critical and emergent injuries compared to low acuity injury at all times of the day and during the rush and non-rush hours. Although the proportion of substance use was higher during the non-rush hour period, the interaction effect of rush hour and substance use resulted in higher odds of critical and emergent injuries compared to low acuity injury. CONCLUSION/CONCLUSIONS:Substance use is associated with increased odds of critical and emergent injury severity. Reducing substance use-related crash injuries may reduce adverse crash injuries.