Vincent E. Chong

Hospital-centered violence intervention programs: a cost-effectiveness analysis

BACKGROUND Hospital-centered violence intervention programs (HVIPs) reduce violent injury recidivism. However, dedicated cost analyses of such programs have not yet been published. We hypothesized that the HVIP at our urban trauma center is a cost-effective means for reducing violent injury recidivism. METHODS We conducted a cost-utility analysis using a state-transition (Markov) decision model, comparing participation in our HVIP with standard risk reduction for patients injured because of firearm violence. Model inputs were derived from our trauma registry and published literature. RESULTS The 1-year recidivism rate for participants in our HVIP was 2.5%, compared with 4% for those receiving standard risk reduction resources. Total per-person costs of each violence prevention arm were similar:

Applying peripheral vascular injury guidelines to penetrating trauma

3,574 for our HVIP and

Computed Tomographic Findings and Mortality in Patients With Pneumomediastinum From Blunt Trauma

3,515 for standard referrals. The incremental cost effectiveness ratio for our HVIP was

Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest

2,941. CONCLUSION Our HVIP is a cost-effective means of preventing recurrent episodes of violent injury in patients hurt by firearms.

Socioeconomic status and the assessment of operative risk

INTRODUCTION Treatment of traumatic vascular injury is evolving because of endovascular therapies. National guidelines advocate for embolization of injuries to lower extremity branch vessels, including pseudoaneurysms or arteriovenous fistulas, in hemodynamically normal patients without hard signs of vascular injury. However, patient stability and injury type may limit endovascular applicability at some centers. We hypothesized that for penetrating trauma, indications for endovascular treatment of peripheral vascular injuries, as outlined by national guidelines, are infrequent. METHODS We reviewed records of patients sustaining penetrating peripheral vascular injuries treated at our university-based urban trauma center from 2006-2010. Patient demographics and outcomes were analyzed. RESULTS In 92 patients with penetrating peripheral vascular injuries, 82 were managed operatively and 10 were managed nonoperatively. Seventeen (18%) were hemodynamically unstable on arrival, 44 (48%) had multiple vessels injured, and 76 (83%) presented at night and/or on the weekend. No pseudoaneurysms or arteriovenous fistulas were seen initially or at follow-up. Applying national guidelines to our cohort, only two patients (2.2%) met recommended criteria for endovascular treatment. CONCLUSIONS According to national guidelines, indications for endovascular treatment of penetrating peripheral vascular injury are infrequent. Nearly two-thirds of patients with penetrating peripheral vascular injuries were hemodynamically unstable or had multiple vessels injured, making endovascular repair less desirable. Additionally, over 80% presented at night and/or on the weekend, which could delay treatment at some centers due to mobilization of the endovascular team. Trauma centers need to consider their resources when incorporating national guidelines in their treatment algorithms of penetrating vascular trauma.

BRAF mutation in papillary thyroid cancer: A cost-utility analysis of preoperative testing.

IMPORTANCE The care of most patients with pneumomediastinum (PNM) due to trauma can be managed conservatively; however, owing to aerodigestive tract injury and other associated injuries, there is a subset of patients with PNM who are at higher risk of mortality but can be difficult to identify. OBJECTIVE To characterize computed tomographic (CT) findings associated with mortality in patients with PNM due to blunt trauma. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of medical records from January 1, 2002, to December 31, 2011, was conducted at a university-based urban trauma center. The patients evaluated were those injured by blunt trauma and found to have PNM on initial chest CT scanning. Data analysis was performed July 2, 2013, to June 18, 2014. MAIN OUTCOMES AND MEASURES In-hospital mortality. RESULTS During the study period, 3327 patients with blunt trauma underwent chest CT. Of these, 72 patients (2.2%) had PNM. Patients with PNM had higher Injury Severity Scores (P < .001) and chest Abbreviated Injury Scale scores (P < .001) compared with those without PNM. Pneumomediastinum was associated with higher mortality (9 [12.5%] vs 118 [3.6%] patients; P < .001) and longer mean (SD) hospital stays (11.3 [14.6] vs 5.1 [8.8] days; P < .001), intensive care unit stays (5.4 [10.2] vs 1.8 [5.7] days; P < .001), and ventilator days (1.7 [4.2] vs 0.6 [4.0] days; P < .03). We evaluated several chest CT findings that may have predictive value. Pneumomediastinum size was not associated with in-hospital mortality (P = .22). However, location of air in the posterior mediastinum was associated with increased mortality of 25% (7 of 28 patients; P = .007). Air in all mediastinal compartments was also associated with increased mortality of 40.0% (4 of 10 patients; P = .01). Presence of hemothorax along with PNM was associated with mortality of 22.2% (8 of 36 patients; P = .01). CONCLUSIONS AND RELEVANCE Pneumomediastinum is uncommon in patients with injury from blunt trauma; however, CT findings of posterior PNM, air in all mediastinal compartments, and concurrent hemothorax are associated with increased mortality. These CT findings could be used as a triage tool to alert the trauma surgeon to a potentially lethal injury.

Neighborhood socioeconomic status is associated with violent reinjury

BACKGROUND The precise role of thoracic CT in penetrating chest trauma remains to be defined. We hypothesized that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM). METHODS A ten-year review of all penetrating torso cases was retrospectively analyzed from our urban University-based trauma center. We included hemodynamically normal patients (systolic blood pressure ≥90) with penetrating chest injuries that underwent screening thoracic CT. Hemodynamically unstable patients and diaphragmatic injuries were excluded. The sensitivity, specificity, positive predictive value and negative predictive value were calculated. RESULTS A total of 212 patients (mean injury severity score=24, Abbreviated Injury Score for Chest=3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM. CONCLUSIONS Thoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings.

Potential disparities in trauma: the undocumented Latino immigrant

STATUS (SES), as measured by education, occupation, and income, have been documented and analyzed extensively. A relationship between SES and mortality has been confirmed in epidemiologic studies in the United Kingdom, Finland, and Russia. In a recent examination of SES relative to inequalities in health among 22 European countries, authors noted an increasing variability of magnitude in disparities of health between countries. There is a 48-year difference in life expectancy among countries worldwide and a 20-year difference within some countries. The World Health Organization believes that social factors are at the root of these disparities, and they have launched a commission on the social determinants of health. The purpose of this work is to promote the incorporation of SES in the preoperative assessment of operative risk. Estimating operative risk is an essential aspect of perioperative decision-making. Surgeons have a multitude of tools designed to assist in this task. Despite an abundance of evidence for the independent effect of SES on operative morbidity and mortality, this variable is conspicuously absent from all standard calculations of operative risk. The reasons for this omission are likely multifactorial. Data on SES are neither easily measurable nor readily available, and SES often is perceived to be immutable in the clinical encounter. Clinicians may therefore gravitate toward seemingly more