Oluwaseyi B. Bolorunduro

Negative appendectomy: a 10-year review of a nationally representative sample

BACKGROUND Appendectomy remains one of the most common emergency surgical procedures encountered throughout the United States. With improvements in diagnostic techniques, the efficiency of diagnosis has increased over the years. However, the entity of negative appendectomies still poses a dilemma because these are associated with unnecessary risks and costs to both patients and institutions. This study was conducted to show current statistics and trends in negative appendectomy rates in the United States. METHODS A retrospective analysis was conducted using data from the National Inpatient Sample from 1998 to 2007. Adult patients (>18 y) having undergone appendectomies were identified by the appropriate International Classification of Diseases 9th revision codes. Patients with incidental appendectomy and those with appendiceal pathologies, also identified by relevant International Classification of Diseases 9th revision codes, were excluded. The remaining patients represent those who underwent an appendectomy without appendiceal disease. The patients then were stratified according to sex, women were classified further into younger (18-45 y) and older (>45 y) based on child-bearing age. The primary diagnoses subsequently were categorized by sex to identify the most common conditions mistaken for appendiceal disease in the 2 groups. RESULTS Between 1998 and 2007, there were 475,651 cases of appendectomy that were isolated. Of these, 56,252 were negative appendectomies (11.83%). There was a consistent decrease in the negative appendectomy rates from 14.7% in 1998 to 8.47% in 2007. Women accounted for 71.6% of cases of negative appendectomy, and men accounted for 28.4%. The mortality rate was 1.07%, men were associated with a higher rate of mortality (1.93% vs .74%; P < .001). Ovarian cyst was the most common diagnosis mistaken for appendicitis in younger women, whereas malignant disease of the ovary was the most common condition mistaken for appendiceal disease in women ages 45 and older. The most common misdiagnosis in men was diverticulitis of the colon. CONCLUSIONS There has been a consistent decline in the rates of negative appendectomy. This trend may be attributed to better diagnostics. Gynecologic conditions involving the ovary are the most common to be misdiagnosed as appendiceal disease in women.

Racial, Ethnic, and Insurance Status Disparities in Use of Posthospitalization Care after Trauma

BACKGROUND Posthospitalization care is important for recovery after trauma. Disadvantaged populations, like racial or ethnic minorities and the uninsured, make up substantial percentages of trauma patients, but their use of posthospitalization facilities is unknown. STUDY DESIGN This study analyzed National Trauma Data Bank admissions from 2007 for 18- to 64-year-olds and estimated relative risk ratios (RRR) of discharge to posthospitalization facilities--home, home health, rehabilitation, or nursing facility--by race, ethnicity, and insurance. Multinomial logistic regression adjusted for patient characteristics including age, sex, Injury Severity Score, mechanism of injury, and length of stay, among others. RESULTS There were 136,239 patients who met inclusion criteria with data for analysis. Most patients were discharged home (78.9%); fewer went to home health (3.3%), rehabilitation (5.0%), and nursing facilities (5.4%). When compared with white patients in adjusted analysis, relative risk ratios of discharge to rehabilitation were 0.61 (95% CI 0.56, 0.66) and 0.44 (95% CI 0.40, 0.49) for blacks and Hispanics, respectively. Compared with privately insured white patients, Hispanics had lower rates of discharge to rehabilitation whether privately insured (RRR 0.45, 95% CI 0.40, 0.52), publicly insured (RRR 0.51, 95% CI 0.42, 0.61), or uninsured (RRR 0.20, 95% CI 0.17, 0.24). Black patients had similarly low rates: private (RRR 0.63, 95% CI 0.56, 0.71), public (RRR 0.72, 95% CI 0.63, 0.82), or uninsured (RRR 0.27, 95% CI 0.23, 0.32). Relative risk ratios of discharge to home health or nursing facilities showed similar trends among blacks and Hispanics regardless of insurance, except for black patients with insurance whose discharge to nursing facilities was similar to their white counterparts. CONCLUSIONS Disadvantaged populations have more limited use of posthospitalization care such as rehabilitation after trauma, suggesting a potential improvement in trauma care for the underprivileged.

Pedestrians struck by motor vehicles further worsen race- and insurance-based disparities in trauma outcomes: the case for inner-city pedestrian injury prevention programs.

BACKGROUND Pedestrian trauma is the most lethal blunt trauma mechanism, and the rate of mortality in African Americans and Hispanics is twice that compared with whites. Whether insurance status and differential survival contribute to this disparity is unknown. METHODS This study is a review of vehicle-struck pedestrians in the National Trauma Data Bank, v7.0. Patients <16 years and > or =65 years, as well as patients with Injury Severity Score (ISS) <9, were excluded. Patients were categorized as white, African American, or Hispanic, and as privately insured, government insured, or uninsured. With white and privately insured patients as reference, logistic regression was used to evaluate mortality by race and insurance status after adjusting for patient and injury characteristics. RESULTS In all, 26,404 patients met inclusion criteria. On logistic regression, African Americans had 22% greater odds of mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.06-1.41) and Hispanics had 33% greater odds of mortality (OR, 1.33; 95% CI, 1.14-1.54) compared with whites. Uninsured patients had 77% greater odds of mortality (OR, 1.77; 95% CI, 1.52-2.06) compared with privately insured patients. CONCLUSION African American and Hispanic race, as well as uninsured status, increase the risk of mortality after pedestrian crashes. Given the greater incidence of pedestrian crashes in minorities, this compounded burden of injury mandates pedestrian trauma prevention efforts in inner cities to decrease health disparities.

Validating the Injury Severity Score (ISS) In Different Populations: ISS Predicts Mortality Better Among Hispanics and Females

INTRODUCTION The Injury Severity Score (ISS) is the most commonly used measure of injury severity. The score has been shown to have excellent predictive capability for trauma mortality and has been validated in multiple data sets. However, the score has never been tested to see if its discriminatory ability is affected by differences in race and gender. OBJECTIVE This study is aimed at validating the ISS in men and women and in three different race/ethnic groups using a nationwide database. METHODS Retrospective analysis of patients age 18-64 y in the National Trauma Data Bank 7.0 with blunt trauma was performed. ISS was categorized as mild (<9,) moderate (9-15), severe (16-25), and profound (>25). Logistic regression was done to measure the relative odds of mortality associated with a change in ISS categories. The discriminatory ability was compared using the receiver operating characteristics curves (ROC). A P value testing the equality of the ROC curves was calculated. Age stratified analyses were also conducted. RESULTS A total of 872,102 patients had complete data for the analysis on ethnicity, while 763,549 patients were included in the gender analysis. The overall mortality rate was 3.7%. ROC in Whites was 0.8617, in Blacks 0.8586, and in Hispanics 0.8869. Hispanics have a statistically significant higher ROC (P value < 0.001). Similar results were observed within each age category. ROC curves were also significantly higher in females than in males. CONCLUSION The ISS possesses excellent discriminatory ability in all populations as indicated by the high ROCs.

Motorcycle Helmets Associated with Lower Risk of Cervical Spine Injury: Debunking the Myth

BACKGROUND There has been a repeal of the universal helmet law in several states despite definitive evidence that helmets reduce mortality, traumatic brain injury, and hospital expenditures. Opponents of the universal helmet law have successfully claimed that helmets should not be required because of greater torque on the neck, which is thought to increase the likelihood of a cervical spine injury. There is currently insufficient evidence to counter claims that helmets do not increase the risk of cervical spine injury after a motorcycle collision. The objective of this study was to determine the impact of motorcycle helmets on the likelihood of developing a cervical spine injury after a motorcycle collision. STUDY DESIGN We reviewed cases in the National Trauma Databank (NTDB) v7.0 involving motorcycle collisions. Multiple logistic regression was used to analyze the independent effect of helmets on cervical spine injury. Cases were adjusted for age, race, sex, insurance status, anatomic (Injury Severity Score) and physiologic injury severity (systolic blood pressure < 90 mmHg), and head injury (Abbreviated Injury Score > 3). RESULTS Between 2002 and 2006, 62,840 cases of motorcycle collision were entered into the NTDB; 40,588 had complete data and were included in the adjusted analysis. Helmeted riders had a lower adjusted odds (0.80 [CI 0.72 to 0.90]) and a lower proportion of cervical spine injury (3.5% vs 4.4%, p < 0.05) compared with nonhelmeted riders. CONCLUSIONS Helmeted motorcyclists are less likely to suffer a cervical spine injury after a motorcycle collision. This finding challenges a long-standing objection to mandatory helmet use that claims helmets are associated with cervical spine injury. Re-enactment of the universal helmet law should be considered in states where it has been repealed.

Pediatric Negative Appendectomy Rate: Trend, Predictors And Differentials

BACKGROUND Appendectomy is one of the most commonly performed emergency operations in children. The diagnosis of appendicitis can be quite challenging, particularly in children. We set out to determine the accuracy of diagnosis of appendicitis by analyzing the trends in the negative appendectomy rate (NAR) using a national database. MATERIALS AND METHODS Analysis of the Kids Inpatient Database (KID) was performed for the years 2000, 2003, and 2006 on children with appendectomy, excluding incidental appendectomies. Children (<18 y) without appendicitis but who underwent appendectomies were classified as negative appendectomies (NA), and those with appendicitis as positive appendectomies (PA). Comparisons were made between those with PA versus NA by demographic characteristics. The subset of patients with NA was then further analyzed. RESULTS An estimated 250,783 appendectomies met the inclusion criteria. The NAR was 6.7%. Length of stay (LOS) was longer in NA versus PA (7 versus 3 d, P < 0.05). The NAR was increased in children under 5 y (21.1% versus 5.4% for among the 5-10 y versus 5.9% among the >10 y, P < 0.0001) and in females (9.3% versus 5.1%, P < 0.001). On multivariate analysis, increasing age was associated with lower odds of NA (OR = 0.92, P < 0.001). Females, rural hospitals, and Blacks were significantly more likely to experience NA. CONCLUSIONS Younger age, female gender, Black ethnicity and rural hospitals are independent predictors of NA. These factors can be incorporated into diagnostic algorithms to improve the accuracy of diagnosis of appendicitis in children.

Eplerenone is not superior to older and less expensive aldosterone antagonists.

INTRODUCTION Eplerenone is publicized to be extremely effective in reducing mortality from heart failure, with a reasonable side-effect profile. However, it is much more expensive compared with older aldosterone antagonists. We reviewed available evidence to assess whether increased expense was justified with outcomes data. METHODS AND RESULTS The authors searched the PubMed, CENTRAL, CINAHL, and EMBASE databases for randomized controlled trials from 1966 through July 2011. Interventions included aldosterone antagonists (Aldactone [Pfizer, NY, NY], canrenone, eplerenone) in systolic heart failure. The comparator included standard medical therapy or placebo, or both. Outcomes assessed were mortality in the intervention versus the comparator groups, and rates of adverse events at the end of at least 8 weeks of follow-up. Event rates were compared using a forest plot of relative risk (RR) (95% confidence interval [CI]) using a random-effects model (Mantel-Haenszel) between the aldosterone antagonists and controls. We included 13 studies for aldosterone antagonists other than eplerenone, and 3 studies for eplerenone. There was significant reduction of mortality with all aldosterone antagonists, but eplerenone (15% mortality relative reduction; RR 0.85; 95% CI, 0.77-0.93; P=.0007) was outperformed by other aldosterone antagonists, namely, spironolactone and canrenone (26% mortality relative reduction; RR 0.74; 95% CI, 0.66-0.83; P <.0001). Reduction in cardiovascular mortality with eplerenone was 17% (RR 0.83; 95% CI, 0.75-0.92; P=.0005), while that with other aldosterone antagonists was 25% (RR 0.75; 95% CI, 0.67-0.84, P <.0001), without contributing significantly to an improved side-effect profile. CONCLUSION Eplerenone does not appear to be more effective in reducing clinical events compared with older, less expensive aldosterone antagonists.

Treatment outcomes of injured children at adult level 1 trauma centers: are there benefits from added specialized care?

BACKGROUND Accidental traumatic injury is the leading cause of morbidity and mortality in children. The authors hypothesized that no mortality difference should exist between children seen at ATC (adult trauma centers) versus ATC with added qualifications in pediatrics (ATC-AQ). METHODS The National Trauma Data Bank, version 7.1, was analyzed for patients aged <18 years seen at level 1 trauma centers. Bivariate analysis compared patients by ATC versus ATC-AQ using demographic and injury characteristics. Multivariate analysis adjusting for injury and demographic factors was then performed. RESULTS A total sample of 53,702 children was analyzed, with an overall mortality of 3.9%. The adjusted odds of mortality was 20% lower for children seen at ATC-AQ (odds ratio, .80; 95% confidence interval, .68-.94). Children aged 3 to 12 years, those with injury severity scores > 25, and those with Glasgow Coma Scale scores < 8 all had significant reductions in the odds of death at ATC-AQ. CONCLUSIONS Improved overall survival is associated with pediatric trauma patients treated at ATC-AQ.

Does the Pattern of Injury in Elderly Pedestrian Trauma Mirror That of The Younger Pedestrian

BACKGROUND Walking is the primary mode of transportation for people aged 65 y and over; hence pedestrian injuries are a substantial source of morbidity and mortality among elderly patients in the United States. This study is aimed at evaluating the pattern of injury in the elderly pedestrians and how it differs from younger patients. METHODS Retrospective analysis of the National Trauma Data Bank (2002-2006) was performed, with inclusion criteria defined as pedestrian injuries based on ICD-9 codes, excluding age < 15 y. The following age categories in years were created: 15-24 (reference group), 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and 85-89. The injury prevalence was compared, and multivariate regression for mortality was conducted adjusting for demographic and injury characteristics. RESULTS A total of 79,307 patients were analyzed. Superficial injuries were the most common at 29.1%, with lower extremity fractures and intracranial injuries following at 25.1% and 21.4% respectively. The very elderly (75-84 and 85-89) had significantly higher rates of fractures of the pelvis(16.2% and 16.8% versus 8.1% in the youngest group), upper (19.3% and 18.4% versus 9.8%), lower extremities (31.1% and 31.9% versus 22.5%) and intracranial injuries (25.5% and 28.7% versus 22.4%), but sustained lower rates of hepatic (2.3% and 1.7% versus 3.0%) injuries, with no difference seen in pancreatic, splenic, and genitourinary injuries. On multivariate analysis, very elderly patients were six to eight times more likely to die (OR 6.24 and 8.27, P < 0.001). CONCLUSION Elderly patients have higher rates of fractures and intracranial injuries with an extremely worse mortality after pedestrian trauma.

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.