Amal L. Khoury

Disparities in trauma care: are fewer diagnostic tests conducted for uninsured patients with pelvic fracture?

BACKGROUND Research from other medical specialties suggests that uninsured patients experience treatment delays, receive fewer diagnostic tests, and have reduced health literacy when compared with their insured counterparts. We hypothesized that these disparities in interventions would not be present among patients experiencing trauma. Our objective was to examine differences in diagnostic and therapeutic procedures administered to patients undergoing trauma with pelvic fractures using a national database. METHODS A retrospective analysis was conducted using the National Trauma Data Bank (NTDB), 2002 to 2006. Patients aged 18 to 64 years who experienced blunt injuries with pelvic fractures were analyzed. Patients who were dead on arrival, those with an injury severity score (ISS) less than 9, those with traumatic brain injury, and patients with burns were excluded. The likelihood of the uninsured receiving select diagnostic and therapeutic procedures was compared with the same likelihood in the insured. Multivariate analysis for mortality was conducted, adjusting for age, sex, race, ISS, presence of shock, Glasgow Coma Scale (GCS) motor score, and mechanism of injury. RESULTS Twenty-one thousand patients met the inclusion criteria: 82% of these patients were insured and 18% were uninsured. There was no clinical difference in ISSs (21 vs 20), but the uninsured were more likely to present in shock (P < .001). The mortality rate in the uninsured was 11.6% vs 5.0% in the insured (P < .001). The uninsured were less likely to receive vascular ultrasonography (P = .01) and computed tomography (CT) of the abdomen (P < .005). There was no difference in the rates of CT of the thorax and abdominal ultrasonography, but the uninsured were more likely to receive radiographs. There was no difference in exploratory laparotomy and fracture reduction, but uninsured patients were less likely to receive transfusions, central venous pressure (CVP) monitoring, or arterial catheterization for embolization. Insurance-based disparities were less evident in level 1 trauma centers. CONCLUSIONS Uninsured patients with pelvic fractures get fewer diagnostic procedures compared with their insured counterparts; this disparity is much greater for more invasive and resource-intensive tests and is less apparent in level 1 trauma centers. Differences in care that patients receive after trauma may be 1 of the mechanisms that leads to insurance disparities in outcomes after trauma.

Radiation combined with thermal injury induces immature myeloid cells.

ABSTRACT The continued development of nuclear weapons and the potential for thermonuclear injury necessitates the further understanding of the immune consequences after radiation combined with injury (RCI). We hypothesized that sublethal ionization radiation exposure combined with a full-thickness thermal injury would result in the production of immature myeloid cells. Mice underwent either a full-thickness contact burn of 20% total body surface area or sham procedure followed by a single whole-body dose of 5-Gy radiation. Serum, spleen, and peripheral lymph nodes were harvested at 3 and 14 days after injury. Flow cytometry was performed to identify and characterize adaptive and innate cell compartments. Elevated proinflammatory and anti-inflammatory serum cytokines and profound leukopenia were observed after RCI. A population of cells with dual expression of the cell surface markers Gr-1 and CD11b were identified in all experimental groups, but were significantly elevated after burn alone and RCI at 14 days after injury. In contrast to the T-cell–suppressive nature of myeloid-derived suppressor cells found after trauma and sepsis, myeloid cells after RCI augmented T-cell proliferation and were associated with a weak but significant increase in interferon &ggr; and a decrease in interleukin 10. This is consistent with previous work in burn injury indicating that a myeloid-derived suppressor cell–like population increases innate immunity. Radiation combined injury results in the increase in distinct populations of Gr-1+CD11b+ cells within the secondary lymphoid organs, and we propose these immature inflammatory myeloid cells provide innate immunity to the severely injured and immunocompromised host.

The trauma safety-net hospital under the Affordable Care Act: will it survive?

O March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA), a historic piece of legislation that could revolutionize the culture of health care delivery and health policy in the United States. The law was designed to improve access, quality, and efficiency of health care delivery while controlling costs and regulating health insurance companies. The ACA amends the Public Health Services Act to prohibit rescissions, strikes down lifetime and annual limits of insurance coverage, and protects Americans with preexisting conditions. Critical to this law is the requirement of minimum essential coverage, either through employers or individual mandate. Medicaid expansion could potentially enroll an additional 15 million Americans, including children in families with household incomes less than 133% of the federal poverty level (FPL). Approximately 92% of Americans will be covered by 2019. However, an estimated 23 million will remain uninsured after the law is fully implemented. National health expenditure constituted 17.9% of the gross domestic product in 2011; to cultivate efficiency and drive down wasteful spending, the ACA calls for reductions in disproportionate share hospital (DSH) funding by 25% to 50%, with further cuts in subsequent years. Theoretically, broadening the proportion of insured patients will ameliorate the burden of uncompensated care on safety-net hospitals and therefore curtail the need for supplemental Medicaid DSH funds. Safety-net hospitals, namely, those that provide trauma care, are especially sensitive to fluctuations in support. The costs and rates of uncompensated care are great. Will trauma safety-net hospitals sink or swim in the changing tides of health care reform? How will we sustain these crucial points of access for our nation’s most vulnerable populations? In this article, we summarize the evolution of DSH funding, explore provisions in the ACA that affect trauma safety-net hospitals, identify possible obstacles, and offer suggestions to mitigate them. BACKGROUND

Predictors for Survival of Penetrating Trauma Using Emergency Department Thoracotomy in an Urban Trauma Center: The Cardiac Instability Score

BACKGROUND Emergency department thoracotomy (EDT) is a procedure used in an attempt to save lives of patients in extremis. This study aims to determine predictors of survival and futility by proposing a scoring scale that measures cardiac instability and its use in predicting survival of victims of penetrating trauma undergoing EDT. METHODS This retrospective study analyzes patients who underwent EDT during a 45-month period at Howard University Hospital, Washington, DC. Vital signs and Glasgow Coma scale (GCS) scores were analyzed at the scene and in the emergency department. A cardiac instability score (CIS) was devised to assign values to vital signs, and the GCS was based on scores from the emergency department. RESULTS Emergency department vital signs, female gender, absence of cardiopulmonary resuscitation (CPR), and high CIS were found to be statistically significant predictors of survival. CONCLUSIONS The CIS correlated with survival of patients who underwent EDT and was found to be statistically significant in determining the outcome of an EDT.

Pediatric Trauma at an Adult Trauma Center

BACKGROUND Accidental traumatic injury is the number 1 cause of morbidity and mortality in the pediatric population. In this study, we aim to prove that certain pediatric patients can be treated with good outcomes at an adult level 1 trauma center. METHODS Retrospective analysis using the Howard University Hospital trauma registry identified 71 patients treated at Howard University Hospital between the ages of 1 and 17 years old. Specific variables were identified and collected for each patient. RESULTS The majority of pediatric traumas treated at Howard University Hospital between June 2004 and May 2005 had high survival rates (93%). The patients who did not survive (7%) included 3 patients who were dead on arrival and 2 who died shortly after arrival to the hospital. CONCLUSIONS Certain pediatric populations who present with minor and/or isolated injuries can be treated in an adult level 1 trauma center with similar outcomes to treatment in a pediatric level 1 trauma center.

Precision surgery and avoiding over-treatment

Over-diagnosis and over-treatment are consequences of greater awareness about breast cancer, more intensive screening, and the resultant identification of more cases of breast cancer that are low or ultralow risk. This area represents an important opportunity to optimize the delivery of appropriate targeted therapy for breast cancer patients. Despite the evolution of breast cancer care over the last few decades and our ability to tailor treatment to biology, a one-size fits all approach is still prevalent in the local and regional management of and screening for breast cancer, failing to reflect the unique biology and tumor characteristics of each patient. In this review, we explore how we can use new tools to better define tumor biology and also how we can change current clinical practices based on already available data. Every surgeon should be knowledgeable about how to craft personalized breast cancer care in the areas of systemic therapy, adjuvant radiation therapy, management of ductal carcinoma in situ (DCIS), precision surgery, and breast cancer screening.

Initial Clinical Experience With an Inducible Magnetic Seed System for Preoperative Breast Lesion Localization

OBJECTIVE The purpose of this study is to evaluate a nonradioactive inducible magnetic seed system (Magseed, Endomag) for preoperative localization of nonpalpable breast lesions. CONCLUSION All of the 73 seeds placed in the first 4 months of clinical use were successfully placed and all were successfully retrieved intraoperatively. The mean time from seed placement to surgery was 3 days. Early clinical experience suggests that Magseed is an effective and accurate means of preoperative breast lesion localization.

Innate immune cell recovery is positively regulated by NLRP12 during emergency hematopoiesis

With enhanced concerns of terrorist attacks, dual exposure to radiation and thermal combined injury (RCI) has become a real threat with devastating immunosuppression. NLRP12, a member of the NOD-like receptor family, is expressed in myeloid and bone marrow cells and was implicated as a checkpoint regulator of inflammatory cytokines, as well as an inflammasome activator. We show that NLRP12 has a profound impact on hematopoietic recovery during RCI by serving as a checkpoint of TNF signaling and preventing hematopoietic apoptosis. Using a mouse model of RCI, increased NLRP12 expression was detected in target tissues. Nlrp12−/− mice exhibited significantly greater mortality, an inability to fight bacterial infection, heightened levels of proinflammatory cytokines, overt granulocyte/monocyte progenitor cell apoptosis, and failure to reconstitute peripheral myeloid populations. Anti-TNF Ab administration improved peripheral immune recovery. These data suggest that NLRP12 is essential for survival after RCI by regulating myelopoiesis and immune reconstitution.