Audrey L Spencer

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Chapters

• Miller, P. R., & Spencer, A. L. (2024). Scapulothoracic dissociation and degloving injuries of the extremities. In 3. Spencer AL, Miller PR. “Scapulothoracic Dissociation and Degloving Injuries of the Extremities.” In: Asensio JA, Meredith WA, editors. Current Therapy of Trauma and Surgical Critical Care, 3rd Edition. Philadelphia, Pennsylvania: Elsevier; 2023.. doi:10.1016/b978-0-323-69787-3.00099-x
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  Scapulothoracic dissociation is an uncommon and an extremely complex and morbid injury with significant morbidity and mortality; however, degloving injuries and open upper extremity injuries and open fractures are considerably more common Scapulothoracic dissociation and upper extremity fractures are caused by high impact trauma. Proper care begins with the initial assessment of this injuries in the pre-hospital arena including hemorrhage control and rapid transport along with prompt transport to a trauma center where initial evaluation and resuscitation includes intravascular volume replacement, assessment of all components of the injured or wounded extremity including vascular, neural, and musculoskeletal components along with the evaluation for the presence of a compartment syndrome, fracture reduction, immediate antibiotic administration (so important to prevent infections), temporary wound coverage, and transport to the operating room for washout and external fixation and/or definitive open reduction and internal fixation (ORIF). Their care usually requires a combined team approach consisting of trauma, orthopedic, plastic surgeons, and neurosurgeons.
• Mowery, N. T., & Spencer, A. L. (2022). Large Bowel Obstruction. In 2. Mowery NT, Spencer AL. “Colon Obstruction.” In: Zielinski MD, Guillamondegui O, editors. The Acute Management of Surgical Disease. Cham, Switzerland: Springer Nature Switzerland AG; 2022.. doi:10.1007/978-3-031-07881-1_13

Journals/Publications

• Anand, T., Hejazi, O., Nelson, A., Litmanovich, B., Spencer, A. L., Khurshid, M. H., Ghaedi, A., Hosseinpour, H., Magnotti, L. J., & Joseph, B. (2025). Early Vasopressor Requirement Among Hypotensive Trauma Patients: Does It Cause More Harm Than Good?. The American surgeon, 91(1), 22-30.
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  Optimal utilization of vasopressors during early post-injury resuscitation remains unclear. Our study aims to describe the relationship between the timing of vasopressor administration and outcomes among hypotensive trauma patients.
• Otaibi, B. W., Khurshid, M. H., Hejazi, O., Hage, K., Stewart, C., Colosimo, C., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2025). The abdomen does not lie, but the labs might: Predictors of intra-abdominal injury on computed tomography imaging in pediatric blunt trauma patients. The journal of trauma and acute care surgery.
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  Multiple studies have indicated that isolated abnormal laboratory results necessitate obtaining abdominal computed tomography (CT) for pediatric patients with blunt abdominal trauma (BAT), regardless of the normal abdominal examination. This study aims to identify the predictors of intra-abdominal injury (IAI) and the role of laboratory tests in CT imaging among pediatric BAT patients.
• Alizai, Q., Arif, M., Colosimo, C., Hosseinpour, H., Spencer, A., Bhogadi, S., Nelson, A., Anand, T., Ditillo, M., & Joseph, B. (2024). Beyond the short-term relief: Outcomes of geriatric rib fracture patients receiving paravertebral nerve blocks and epidural analgesia. Injury, 55(1). doi:10.1016/j.injury.2023.111184
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  Background: Adequate pain control is a critical component of rib fracture management. Our study aimed to evaluate the in-hospital and post-discharge outcomes of geriatric rib fracture patients who received paravertebral nerve block (PVNB) versus epidural analgesia (EA) on a national level. Methods: We performed a 5-year (2011–15) retrospective analysis of the Nationwide Readmission database. We included all the geriatric (≥65 years) blunt trauma patients with rib fractures who received a paravertebral nerve block (PVNB) or Epidural analgesia (EA) for chest injuries. We excluded patients who were dead on arrival, those with head AIS≥3, spine AIS >0, and those with cognitive impairment. Patients were stratified into two groups (PVNB and EA). A propensity score matching (1:2) was performed, and the two groups were compared. Our outcomes included delirium, hospital length of stay (LOS), 90-day readmissions, 90-day mechanical ventilation, and initial and 90-day mortality. Results: A total of 2,855 geriatric rib fracture patients were identified, out of which 352 (12 %) received PVNB and 2,503 (87 %) received EA. The mean (SD) age was 78 (8) years and 53 % were female. A total of 1,041 patients were matched (PVNB=347, EA=694 patients). The median [IQR] Injury severity score was 9 [3–15], median chest AIS was 3 [2–4], and 70 % had ≥3 rib fractures. The total mortality during index admission was 6 %, 13 % experienced delirium, and the median hospital LOS was 6 [4–10] days. There was no difference in the primary outcomes of the two groups including rates of index admission mortality (PVNB: 5.2% vs. EA:6.3 %, p = 0.548) and delirium (PVNB: 12.4% vs. EA:12.9 %, p = 0.862). We also found no statistically significant difference between these groups in terms of 90-day respiratory complications (p = 1.000), 90-day readmission (p = 0.111), 90-day mortality (p = 0.718), and 90-day need for mechanical ventilation (p = 1.000). Conclusion: The use of PVNB in geriatric trauma patients with multiple rib fractures is associated with comparable in-hospital and post-discharge outcomes relative to EA. PVNB is relatively easy to perform and has a better side effect profile. The use of PVNB as part of rib fracture management protocols warrants further consideration. Level of evidence: III Study type: Therapeutic/Care Management
• Anand, T., Hejazi, O., Conant, M., Joule, D., Lundy, M., Colosimo, C., Spencer, A., Nelson, A., Magnotti, L., & Joseph, B. (2024). Impact of resuscitation adjuncts on postintubation hypotension in patients with isolated traumatic brain injury. Journal of Trauma and Acute Care Surgery, 97(1). doi:10.1097/TA.0000000000004306
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  INTRODUCTION Postintubation hypotension (PIH) is a risk factor of endotracheal intubation (ETI) after injury. For those with traumatic brain injury (TBI), one episode of hypotension can potentiate that injury. This study aimed to identify the resuscitation adjuncts that may decrease the incidence of PIH in this patient population. METHODS This is a 4-year (2019-2022) prospective observational study at a level I trauma center. Adult (18 years or older) patients with isolated TBI requiring ETI in the trauma bay were included. Blood pressures were measured 15 minutes preintubation and postintubation. Primary outcome was PIH, defined as a decrease in systolic blood pressure of ≥20% from baseline or to ≤80 mm Hg, or any decrease in mean arterial pressure to ≤60 mm Hg. Multivariable logistic regression was performed to identify the associations of preintubation vasopressor, hypertonic saline (HTS), packed red blood cell, and crystalloids on PIH incidence. RESULTS Of the 490 enrolled patients, 16% had mild (head AIS, ≤2), 35% had moderate (head AIS, 3-4), and 49% had severe TBI (head AIS, ≥5). The mean ± SD age was 42 ± 22 years, and 71% were male. The median ISS, head AIS, and Glasgow Coma Scale were 26 (19-38), 4 (3-5), and 6 (3-11), respectively. The mean ± SD systolic blood pressure 15 minutes preintubation and postintubation were 118 ± 46 and 106 ± 45, respectively. Before intubation, 31% received HTS; 10%, vasopressors; 20%, crystalloids; and 14%, at least 1 U of packed red blood cell (median, 2 [1-2] U). Overall, 304 patients (62%) developed PIH. On multivariable regression analysis, preintubation use of vasopressors and HTS was associated with significantly decreased odds of PIH independent of TBI severity, 0.310 (0.102-0.944, p = 0.039) and 0.393 (0.219-0.70, p = 0.002), respectively. CONCLUSION Nearly two thirds of isolated TBI patients developed PIH. Preintubation vasopressors and HTS are associated with a decreased incidence of PIH. Such adjuncts should be considered prior to ETI in patients with suspected TBI.
• Anand, T., Hejazi, O., Conant, M., Joule, D., Lundy, M., Colosimo, C., Spencer, A., Nelson, A., Magnotti, L., & Joseph, B. (2024). Impact of resuscitation adjuncts on postintubation hypotension in patients with isolated traumatic brain injury. The journal of trauma and acute care surgery, 97(1), 112-118.
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  Postintubation hypotension (PIH) is a risk factor of endotracheal intubation (ETI) after injury. For those with traumatic brain injury (TBI), one episode of hypotension can potentiate that injury. This study aimed to identify the resuscitation adjuncts that may decrease the incidence of PIH in this patient population.
• Appelbaum, R. D., Puzio, T. J., Bauman, Z., Asfaw, S., Spencer, A., Dumas, R. P., Kaur, K., Cunningham, K. W., Butler, D., Sawhney, J. S., Gadomski, S., Horwood, C. R., Stuever, M., Sapp, A., Gandhi, R., & Freeman, J. (2024). Handoffs and transitions of care: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. The journal of trauma and acute care surgery, 97(2), 305-314.
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  The Joint Commission reports that at least half of communication breakdowns occur during handovers or transitions of care. There is no consensus on how best to approach the transfer of care within acute care surgery (ACS). We conduct a systematic review and meta-analysis of the current data on handoffs and transitions of care in ACS patients and evaluate the impact of standardization and formalized communication processes.
• Appelbaum, R., Puzio, T., Bauman, Z., Asfaw, S., Spencer, A., Dumas, R., Kaur, K., Cunningham, K., Butler, D., Sawhney, J., Gadomski, S., Horwood, C., Stuever, M., Sapp, A., Gandhi, R., & Freeman, J. (2024). Handoffs and transitions of care: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, 97(2). doi:10.1097/TA.0000000000004285
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  BACKGROUND The Joint Commission reports that at least half of communication breakdowns occur during handovers or transitions of care. There is no consensus on how best to approach the transfer of care within acute care surgery (ACS). We conduct a systematic review and meta-analysis of the current data on handoffs and transitions of care in ACS patients and evaluate the impact of standardization and formalized communication processes. METHODS Clinically relevant questions regarding handoffs and transitions of care with clearly defined patient Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes were determined. These centered around specific transitions of care within the setting of ACS, specifically perioperative interactions, emergency medical services and trauma team interactions, and intra/interfloor and intensive care unit (ICU) interactions. A systematic literature review and meta-analysis were conducted using the Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS A total of 10 studies were identified for analysis. These included 5,113 patients in the standardized handoff group and 5,293 in the current process group. Standardized handoffs reduced handover errors for perioperative interactions and preventable adverse events for intra/interfloor and ICU interactions. There were insufficient data to evaluate outcomes of clinical complications and medical errors. CONCLUSION We conditionally recommend a standardized handoff in the field of ACS, including perioperative interactions, emergency medical services and trauma team interactions, and intra/interfloor and ICU interactions. LEVEL OF EVIDENCE Systematic Review/Meta-analysis; Level III.
• Bhogadi, S. K., Ditillo, M., Khurshid, M. H., Stewart, C., Hejazi, O., Spencer, A. L., Anand, T., Nelson, A., Magnotti, L. J., & Joseph, B. (2024). Development and Validation of Futility of Resuscitation Measure in Older Adult Trauma Patients. The Journal of surgical research, 301, 591-598.
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  This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients.
• Bhogadi, S. K., El-Qawaqzeh, K., Colosimo, C., Hosseinpour, H., Magnotti, L. J., Spencer, A. L., Anand, T., Ditillo, M., Alizai, Q., Nelson, A., & Joseph, B. (2024). Pediatric Acute Compartment Syndrome in Long Bone Fractures: Who is at Risk?. Journal of Surgical Research. doi:10.1016/j.jss.2024.01.032
• Bhogadi, S. K., El-Qawaqzeh, K., Colosimo, C., Hosseinpour, H., Magnotti, L. J., Spencer, A. L., Anand, T., Ditillo, M., Alizai, Q., Nelson, A., & Joseph, B. (2024). Pediatric Acute Compartment Syndrome in Long Bone Fractures: Who is at Risk?. The Journal of surgical research, 298, 53-62.
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  There is a paucity of large-scale data on the factors that suggest an impending or underlying extremity pediatric acute compartment syndrome (ACS). In addition, literature regarding the timing of operative fixation and the risk of ACS is mixed. We aimed to describe the factors associated with pediatric ACS.
• Bhogadi, S. K., Hejazi, O., Nelson, A., Stewart, C., Hosseinpour, H., Spencer, A. L., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Surgical stabilization of rib fractures: The impact of volume and the need for standardized indications. American journal of surgery, 234, 112-116.
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  We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF.
• Bhogadi, S. K., Nelson, A., Hosseinpour, H., Anand, T., Hejazi, O., Colosimo, C., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Effect of PCC on outcomes of severe traumatic brain injury patients on preinjury anticoagulation. American journal of surgery, 232, 138-141.
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  This study aims to evaluate effect of 4-factor PCC on outcomes of severe TBI patients on preinjury anticoagulants undergoing craniotomy/craniectomy.
• Bhogadi, S., Ditillo, M., Khurshid, M., Stewart, C., Hejazi, O., Spencer, A., Anand, T., Nelson, A., Magnotti, L., & Joseph, B. (2024). Development and Validation of Futility of Resuscitation Measure in Older Adult Trauma Patients. Journal of Surgical Research, 301. doi:10.1016/j.jss.2024.07.019
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  Introduction: This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients. Methods: This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2018) (derivation cohort) and American College of Surgeons level I trauma center database (2017-2022) (validation cohort). We included all severely injured (injury severity score >15) older adult (aged ≥60 y) trauma patients. Patients were stratified into decades of age. Injury characteristics (severe traumatic brain injury [Glasgow Coma Scale ≤ 8], traumatic brain injury midline shift), physiologic parameters (lowest in-hospital systolic blood pressure [≤1 h], prehospital cardiac arrest), and interventions employed (4-h packed red blood cell transfusions, emergency department resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta, emergency laparotomy [≤2 h], early vasopressor requirement [≤6 h], and craniectomy) were identified. Regression coefficient-based weighted scoring system was developed using the Schneeweiss method and subsequently validated using institutional database. Results: A total of 5562 patients in derivation cohort and 873 in validation cohort were identified. Mortality was 31% in the derivation cohort and FoRM had excellent discriminative power to predict mortality (area under the receiver operator characteristic = 0.860; 95% confidence interval [0.847-0.872], P < 0.001). Patients with a FoRM score of >16 had a less than 10% chance of survival, while those with a FoRM score of >20 had a less than 5% chance of survival. In validation cohort, mortality rate was 17% and FoRM had good discriminative power (area under the receiver operator characteristic = 0.76; 95% confidence interval [0.71-0.80], P < 0.001). Conclusions: FoRM can reliably identify the risk of futile resuscitation among older adult patients admitted to our level I trauma center.
• Bhogadi, S., El-Qawaqzeh, K., Colosimo, C., Hosseinpour, H., Magnotti, L., Spencer, A., Anand, T., Ditillo, M., Alizai, Q., Nelson, A., & Joseph, B. (2024). Pediatric Acute Compartment Syndrome in Long Bone Fractures: Who is at Risk?. Journal of Surgical Research, 298. doi:10.1016/j.jss.2024.01.032
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  Introduction: There is a paucity of large-scale data on the factors that suggest an impending or underlying extremity pediatric acute compartment syndrome (ACS). In addition, literature regarding the timing of operative fixation and the risk of ACS is mixed. We aimed to describe the factors associated with pediatric ACS. Methods: Analysis of 2017-2019 Trauma Quality Improvement Program. We included patients aged
• Bhogadi, S., Hejazi, O., Nelson, A., Stewart, C., Hosseinpour, H., Spencer, A., Anand, T., Ditillo, M., Magnotti, L., & Joseph, B. (2024). Surgical stabilization of rib fractures: The impact of volume and the need for standardized indications. American Journal of Surgery, 234. doi:10.1016/j.amjsurg.2024.03.019
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  Introduction: We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF. Methods: Blunt rib fracture patients who underwent SSRF were included from ACS-TQIP2017-2021. TCs were stratified according to tertiles of SSRF volume:low (LV), middle, and high (HV). Outcomes were time to SSRF, respiratory complications, prolonged ventilator use, mortality. Results: 16,872 patients were identified (LV:5470,HV:5836). Mean age was 56 years, 74% were male, median thorax-AIS was 3. HV centers had a lower proportion of patients with flail chest (HV41% vs LV50%), pulmonary contusion (HV44% vs LV52%) and had shorter time to SSRF(HV58 vs LV76 ​h), less respiratory complications (HV3.2% vs LV4.5%), prolonged ventilator use (HV15% vs LV26%), mortality (HV2% vs LV2.6%) (all p ​< ​0.05). On multivariable regression analysis, HV centers were independently associated with reduced time to SSRF(β ​= ​−18.77,95%CI ​= ​−21.30to-16.25), respiratory complications (OR ​= ​0.67,95%CI ​= ​0.49–0.94), prolonged ventilator use (OR ​= ​0.49,95%CI ​= ​0.41–0.59), but not mortality. Conclusions: HV SSRF centers have improved outcomes, however, there are variations in threshold for SSRF and indications must be standardized. Level of evidence: Level III. Study type: Therapeutic/Care Management.
• Bhogadi, S., Nelson, A., Hosseinpour, H., Anand, T., Hejazi, O., Colosimo, C., Spencer, A., Ditillo, M., Magnotti, L., & Joseph, B. (2024). Effect of PCC on outcomes of severe traumatic brain injury patients on preinjury anticoagulation. American Journal of Surgery, 232. doi:10.1016/j.amjsurg.2024.01.035
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  Introduction: This study aims to evaluate effect of 4-factor PCC on outcomes of severe TBI patients on preinjury anticoagulants undergoing craniotomy/craniectomy. Methods: In this analysis of 2018–2020 ACS-TQIP, patients with isolated blunt severe TBI (Head-AIS≥3, nonhead-AIS
• Colosimo, C., Bhogadi, S. K., Hejazi, O., Nelson, A., Hosseinpour, H., Stewart, C., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). When Every Minute Counts: REBOA Before Surgery Is Independently Associated With a 15-Minute Delay in Time to Definitive Hemorrhage Control. Military medicine, 189(Suppl 3), 262-267.
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  Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing hemorrhage control intervention, but its inevitable effect on time to operating room (OR) has not been assessed. The aim of our study is to assess the impact of undergoing REBOA before surgery (RBS) on time to definitive hemorrhage control surgery.
• Colosimo, C., Bhogadi, S., Hejazi, O., Nelson, A., Hosseinpour, H., Stewart, C., Spencer, A., Ditillo, M., Magnotti, L., & Joseph, B. (2024). When Every Minute Counts: REBOA Before Surgery Is Independently Associated With a 15-Minute Delay in Time to Definitive Hemorrhage Control. Military Medicine, 189. doi:10.1093/milmed/usae089
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  Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing hemorrhage control intervention, but its inevitable effect on time to operating room (OR) has not been assessed. The aim of our study is to assess the impact of undergoing REBOA before surgery (RBS) on time to definitive hemorrhage control surgery. Methods: In this retrospective analysis of 2017-2021 ACS-TQIP database, all adult (≥18 years) patients who underwent emergency hemorrhage control laparotomy (≤4 hours of admission) and received early blood products (≤4 hours) were included, and patients with severe head injury (Head-abbreviated injury score > 2) were excluded. Patients were stratified into those who did (RBS) vs those who did not undergo REBOA before surgery (No-RBS). Primary outcome was time to laparotomy. Secondary outcomes were complications and mortality. Multivariable linear and binary logistic regression analyses were performed to identify the independent associations between RBS and outcomes. Results: A total of 32,683 patients who underwent emergency laparotomy were identified (RBS: 342; No-RBS: 32,341). The mean age was 39 (16) years, 78% were male, mean SBP was 107 (34) mmHg, and the median injury severity score was 21 [14-29]. The median time to emergency hemorrhage control surgery was 50 [32-85] minutes. Overall complication rate was 16% and mortality was 19%. On univariate analysis, RBS group had longer time to surgery (RBS 56 [41-89] vs No-RBS 50 [32-85] minutes, P < 0.001). On multivariable analysis, RBS was independently associated with a longer time to hemorrhage control surgery (β + 14.5 [95%CI 7.8-21.3], P < 0.001), higher odds of complications (aOR = 1.72, 95%CI = 1.27-2.34, P < 0.001), and mortality (aOR = 3.42, 95%CI = 2.57-4.55, P < 0.001). Conclusion: REBOA is independently associated with longer time to OR for hemorrhaging trauma patients with an average delay of 15 minutes. Further research evaluating center-specific REBOA volume and utilization practices, and other pertinent system factors, may help improve both time to REBOA as well as time to definitive hemorrhage control across US trauma centers.
• Colosimo, C., Otaibi, B., Bhogadi, S. K., Nelson, A., Spencer, A. L., Anand, T., Stewart, C., Magnotti, L. J., & Joseph, B. (2024). Obesity is a predictor of abdominal computed tomography imaging in pediatric trauma patients. The journal of trauma and acute care surgery.
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  Computed tomography (CT) has helped to reduce the morbidity due to missed injuries. However, CT imaging is associated with radiation exposure and thus has limited indications in pediatric patients. In this study, we aimed to identify the association between obesity and abdominal CT imaging in pediatric trauma patients.
• Colosimo, C., Otaibi, B., Bhogadi, S., Nelson, A., Spencer, A., Anand, T., Stewart, C., Magnotti, L., & Joseph, B. (2024). Obesity is a predictor of abdominal computed tomography imaging in pediatric trauma patients. Journal of Trauma and Acute Care Surgery, 97(6). doi:10.1097/TA.0000000000004424
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  BACKGROUND Computed tomography (CT) has helped to reduce the morbidity due to missed injuries. However, CT imaging is associated with radiation exposure and thus has limited indications in pediatric patients. In this study, we aimed to identify the association between obesity and abdominal CT imaging in pediatric trauma patients. METHODS We performed a 4-year retrospective analysis of the American College of Surgeons Trauma Quality Improvement 2017-2020. We identified all pediatric trauma patients aged between 7 and 17 years presenting with isolated abdominal trauma (nonabdominal Abbreviated Injury Scale score, 0). We excluded patients undergoing hemorrhage control surgeries and those with missing information in height and weight. Patients were stratified by body mass index into four groups (underweight, normal, overweight, and obese [body mass index, ≥30 kg/m2]). Outcomes were predictors of undergoing CT imaging of the abdomen. Descriptive statistics and multivariable logistic regression analyses were performed. RESULTS We identified a total of 10,204 pediatric trauma patients. The mean age was 13 years, 68% were male, and 77% were White. The median abdominal Abbreviated Injury Scale score in all the four groups was 2. On univariate analysis, underweight patients had lowest rates (25%), whereas obese patients had highest rates of CT imaging (38%) (p < 0.001). On multivariable regression analysis, increasing age (adjusted odds ratio [aOR], 1.08; 95% confidence interval [CI], 1.06-1.10; p < 0.001), male sex (aOR, 1.14; 95% CI, 1.03-1.26; p = 0.009), White race (aOR, 0.84; 95% CI, 0.76-0.92; p < 0.011), penetrating injury (aOR, 1.16; 95% CI, 1.03-1.32; p = 0.017), obesity (aOR, 1.30; 95% CI, 1.07-1.57; p = 0.008), and management at American College of Surgeons level II (aOR, 1.63; 95% CI, 1.44-1.85; p < 0.001) and level III or lower centers (aOR, 1.17; 95% CI, 1.06-1.26; p = 0.002) were identified as independent predictors of receiving CT imaging. CONCLUSION Obesity is associated with increased odds of undergoing CT imaging in pediatric trauma patients independent of injury characteristics. Future efforts to define the appropriate indications for CT imaging in pediatric trauma patients are warranted to reduce the adverse effects of CT radiation. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
• Culbert, M. H., Bhogadi, S. K., Hosseinpour, H., Colosimo, C., Alizai, Q., Anand, T., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen. The Journal of surgical research, 298, 7-13.
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  Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen.
• Culbert, M., Bhogadi, S., Hosseinpour, H., Colosimo, C., Alizai, Q., Anand, T., Spencer, A., Ditillo, M., Magnotti, L., & Joseph, B. (2024). Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen. Journal of Surgical Research, 298. doi:10.1016/j.jss.2023.12.046
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  Introduction: Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen. Methods: In this analysis of 2017-2021 American College of Surgeons-Trauma Quality Improvement Program (ACS TQIP), adult(≥18 y) patients with SUD and positive drug screen who survived the hospital admission were included. Outcomes measure was the receipt of MHS. Poisson regression analysis with clustering by facility was performed to identify independent predictors of receipt of MHS. Results: 128,831 patients were identified of which 3.4% received MHS. Mean age was 41 y, 76% were male, 63% were White, 25% were Black, 12% were Hispanic, and 82% were insured. Median injury severity score was 9, and 54% were managed at an ACS level I trauma center. On regression analysis, female gender (aOR = 1.17, 95% CI = 1.09-1.25), age ≥65 y (aOR = 0.98, 95% CI = 0.97-0.99), White race (aOR = 1.37, 95% CI = 1.28-1.47), Hispanic ethnicity (aOR = 0.84, 95% CI = 0.76-0.93), insured status (aOR = 1.22, 95% CI = 1.13-1.33), and management at ACS level I trauma centers (aOR = 1.47, 95% CI = 1.38-1.57) were independent predictors of receipt of MHS. Conclusions: Race, ethnicity, and socioeconomic factors predict the receipt of MHS in trauma patients with SUD and positive drug screens. It is unknown if these disparities affect the long-term outcomes of these vulnerable patients. Further research is warranted to expand on the contributing factors leading to these disparities and possible strategies to address them.
• El-Qawaqzeh, K., Magnotti, L., Hosseinpour, H., Nelson, A., Spencer, A., Anand, T., Bhogadi, S., Alizai, Q., Ditillo, M., & Joseph, B. (2024). Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes? Outcomes of Geriatric Patients in Trauma Centers. Injury, 55(1). doi:10.1016/j.injury.2023.110972
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  Introduction: It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients’ outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes. Study Design: Patients ≥65 years were identified from the Trauma Quality Improvement Program (TQIP) database (2017–2019). Patients transferred, discharged from emergency department (ED), and those with head abbreviated injury scale >3 were excluded. 11-factor modified frailty index was utilized. Propensity score matching (1:1) was performed. Outcomes included discharge to skilled nursing facility or rehab (SNF/rehab), withdrawal of life-supporting treatment (WLST), mortality, complications, failure-to-rescue, intensive care unit (ICU) admission, hospital length of stay (LOS), and ventilator days. Results: 110,680 patients were matched (Frail:55,340, Non-Frail:55,340). Mean age was 79 (7), 90% presented following falls, and median ISS was 5 [2–9]. Level-I/II TCs had lower rates of discharge to SNF/rehab (52.6% vs. 55.8% vs. 60.9%; p < 0.001), failure-to-rescue (0.5% vs. 0.4% vs. 0.6%;p = 0.005), and higher rates of WLST (2.4% vs. 2.1% vs. 0.3%; p < 0.001) compared to level-III regardless of injury severity and frailty. Compared to Level-III centers, Level-I/II centers had higher complications among moderate-to-severely injured patients (4.1% vs. 3.3% vs. 2.7%; p < 0.001), and lower mortality only among frail patients regardless of injury severity (1.8% vs. 1.5% vs. 2.6%; p < 0.001). Patients at Level-I TCs were more likely to be admitted to ICU, and had longer hospital LOS and ventilator days compared to Level-II and III TCs (p < 0.05). Conclusion: Frailty may play an important role when triaging geriatric trauma patients. In fact, the benefit of care at higher-level TCs is particularly evident for patients who are frail. Level III centers may be underperforming in providing access to palliative and end-of-life care.
• Hejazi, O., Ghaedi, A., Stewart, C., Khurshid, M. H., Spencer, A. L., Hosseinpour, H., Nelson, A., Bhogadi, S. K., Magnotti, L. J., & Joseph, B. (2024). The Harsh Reality: Outcomes of Patients With Operatively Managed Lung Injuries. The Journal of surgical research, 302, 656-661.
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  Most traumatic lung injuries are managed non-operatively. There is a paucity of recent data on the outcomes of operatively managed lung injuries. The aim of our study is to determine the survival rates of operatively managed traumatic lung injury patients on a nationwide scale.
• Hejazi, O., Ghaedi, A., Stewart, C., Khurshid, M., Spencer, A., Hosseinpour, H., Nelson, A., Bhogadi, S., Magnotti, L., & Joseph, B. (2024). The Harsh Reality: Outcomes of Patients With Operatively Managed Lung Injuries. Journal of Surgical Research, 302. doi:10.1016/j.jss.2024.07.053
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  Introduction: Most traumatic lung injuries are managed non-operatively. There is a paucity of recent data on the outcomes of operatively managed lung injuries. The aim of our study is to determine the survival rates of operatively managed traumatic lung injury patients on a nationwide scale. Methods: We performed a retrospective analysis of the ACS-TQIP 2017-2020. We included all adult trauma patients with lung injuries that underwent operative management. Patients were stratified based on type of surgery into 3 groups (wedge resection, lobectomy, pneumonectomy). The outcome was mortality. Multivariable logistic regression analysis was performed to identify the independent predictors of mortality. Results: We identified a total of 170,377 patients with lung injuries, out of which 2159 (1.3%) patients underwent operative management (Wedge resection [61%], Lobectomy [31%], Pneumonectomy [8%]). Among operatively managed patients, the mean (SD) age was 37 (16) years, and 86% were male. Overall, 65% sustained penetrating injuries, with a median [IQR] ISS of 25 [16 – 33], and median [IQR] lung injury AIS severity of 4 [3 – 4]. About 7% of the patients suffered hilar injuries. The mean (SD) SBP on arrival was 108 (43) and the median [IQR] time to surgery was 177 [52 – 5351] minutes. The median hospital LOS was 10 [1 – 19] days, and overall mortality rate was 30%. On univariate analysis, patients undergoing pneumonectomy had the highest mortality (54%), followed by lobectomy (33%), and wedge resection (25%). On multivariable regression analysis, hilar injuries (aOR 1.9, 95%CI = 1.06 – 2.80, P = 0.029), increasing age (aOR 1.02, 95%CI = 1.01 – 1.03, P = 0.001), concomitant head (aOR 1.34, 95%CI = 1.22 – 1.47, P < 0.001) and abdominal injuries (aOR 1.42, 95%CI = 1.31 – 1.54, P < 0.001) were independent predictors of mortality. Conclusions: Nearly 1 in 3 patients with lung injuries who were managed operatively did not survive their index admission. These findings highlight that operatively managed lung injuries still carry a high risk of mortality and should be reserved for selected patients. The decision for surgery in patients with concomitant head or abdominal injuries must be taken on a case-to-case basis.
• Hejazi, O., Spencer, A. L., Khurshid, M. H., Nelson, A., Hosseinpour, H., Anand, T., Bhogadi, S. K., Matthews, M. R., Magnotti, L. J., & Joseph, B. (2024). Failure to Rescue in Geriatric Ground-Level Falls: The Role of Frailty on Not-So-Minor Injuries. The Journal of surgical research, 302, 891-896.
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  The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs).
• Hejazi, O., Spencer, A., Khurshid, M., Nelson, A., Hosseinpour, H., Anand, T., Bhogadi, S., Matthews, M., Magnotti, L., & Joseph, B. (2024). Failure to Rescue in Geriatric Ground-Level Falls: The Role of Frailty on Not-So-Minor Injuries. Journal of Surgical Research, 302. doi:10.1016/j.jss.2024.07.095
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  Introduction: The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs). Methods: This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2020). All geriatric (aged ≥ 65 ys) trauma patients with GLFs admitted to a level I trauma center were included. Transferred patients, those with severe head injuries (head abbreviated injury scale ≥ 3), and those who died within 24 h of admission or whose length of stay was ≤1 d were excluded. FTR was defined as death following a major complication (cardiac arrest, myocardial infarction, sepsis, acute respiratory distress syndrome, unplanned intubation, acute renal failure, cerebrovascular accident, ventilator-associated pneumonia, or pulmonary embolism). Patients were stratified into frail (F) and nonfrail (NF) based on the 11-Factor Modified Frailty Index. Multivariable regression analyses were performed to identify the independent effect of frailty on the incidence of FTR. Results: Over 4 ys, 34,100 geriatric patients with GLFs were identified, of whom 9140 (26.8%) were F. The mean (standard deviation) age was 78 (7) years and 65% were female. The median injury severity score was 9 (5-10) with no difference among F and NF groups (P = 0.266). Overall, F patients were more likely to develop major complications (F: 3.6% versus NF: 2%, P < 0.001) and experience FTR (F: 1.8%% versus NF: 0.6%, P < 0.001). Moreover, among patients with major complications, F patients were more likely to die (F: 47% versus NF: 27%, P < 0.001). On multivariable regression analysis, frailty was identified as an independent predictor of major complications (adjusted odds ratio: 1.98, 95% confidence interval [1.70-2.29], P < 0.001) and FTR (adjusted odds ratio: 2.26, 95% confidence interval [1.68-3.05], P < 0.001). Conclusions: Among geriatric trauma patients with GLFs, frailty increases the risk-adjusted odds of FTR by more than two times. One in every two F patients with a major complication does not survive to discharge. Future efforts should concentrate on improving patient-related and hospital-related factors to decrease the risk of FTR among these vulnerable populations.
• Hosseinpour, H., Anand, T., Hejazi, O., Colosimo, C., Bhogadi, S. K., Spencer, A., Nelson, A., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). The Role of Whole Blood Hemostatic Resuscitation in Bleeding Geriatric Trauma Patients. The Journal of surgical research, 299, 26-33.
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  Whole blood (WB) has recently gained increased popularity as an adjunct to the resuscitation of hemorrhaging civilian trauma patients. We aimed to assess the nationwide outcomes of using WB as an adjunct to component therapy (CT) versus CT alone in resuscitating geriatric trauma patients.
• Hosseinpour, H., Anand, T., Hejazi, O., Colosimo, C., Bhogadi, S., Spencer, A., Nelson, A., Ditillo, M., Magnotti, L., & Joseph, B. (2024). The Role of Whole Blood Hemostatic Resuscitation in Bleeding Geriatric Trauma Patients. Journal of Surgical Research, 299. doi:10.1016/j.jss.2024.03.050
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  Introduction: Whole blood (WB) has recently gained increased popularity as an adjunct to the resuscitation of hemorrhaging civilian trauma patients. We aimed to assess the nationwide outcomes of using WB as an adjunct to component therapy (CT) versus CT alone in resuscitating geriatric trauma patients. Methods: We performed a 5-y (2017-2021) retrospective analysis of the Trauma Quality Improvement Program. We included geriatric (age, ≥65 y) trauma patients presenting with hemorrhagic shock (shock index >1) and requiring at least 4 units of packed red blood cells in 4 h. Patients with severe head injuries (head Abbreviated Injury Scale ≥3) and transferred patients were excluded. Patients were stratified into WB-CT versus CT only. Primary outcomes were 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications. Multivariable regression analysis was performed, adjusting for potential confounding factors. Results: A total of 1194 patients were identified, of which 141 (12%) received WB. The mean ± standard deviation age was 74 ± 7 y, 67.5% were male, and 83.4% had penetrating injuries. The median [interquartile range] Injury Severity Score was 19 [13-29], with no difference among study groups (P = 0.059). Overall, 6-h, 24-h, and in-hospital mortality were 16%, 23.1%, and 43.6%, respectively. On multivariable regression analysis, WB was independently associated with reduced 24-h (odds ratio, 0.62 [0.41-0.94]; P = 0.024), and in-hospital mortality (odds ratio, 0.60 [0.40-0.90]; P = 0.013), but not with major complications (odds ratio, 0.78 [0.53-1.15]; P = 0.207). Conclusions: Transfusion of WB as an adjunct to CT is associated with improved early and overall mortality in geriatric trauma patients presenting with severe hemorrhage. The findings from this study are clinically important, as this is an essential first step in prioritizing the selection of WB resuscitation for geriatric trauma patients presenting with hemorrhagic shock.
• Joseph, B., Hosseinpour, H., Sakran, J. V., Anand, T., Colosimo, C., Nelson, A., Stewart, C., Spencer, A. L., Zhang, B., & Magnotti, L. J. (2024). Defining the Problem: 53 Years of Firearm Violence Afflicting America’s Schools. Journal of the American College of Surgeons, 238(4), 671-678. doi:10.1097/xcs.0000000000000955
• Joseph, B., Hosseinpour, H., Sakran, J., Anand, T., Colosimo, C., Nelson, A., Stewart, C., Spencer, A. L., Zhang, B., & Magnotti, L. J. (2024). Defining the Problem: 53 Years of Firearm Violence Afflicting America's Schools. Journal of the American College of Surgeons, 238(4), 671-678.
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  Firearm violence and school shootings remain a significant public health problem. This study aimed to examine how publicly available data from all 50 states might improve our understanding of the situation, firearm type, and demographics surrounding school shootings.
• Khurshid, M. H., Yang, A. R., Hosseinpour, H., Colosimo, C., Hejazi, O., Spencer, A. L., Bhogadi, S. K., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Final Lifelines: The Implications and Outcomes of Thoracic Damage Control Surgeries. The Journal of surgical research, 301, 385-391.
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  There is a lack of data on the outcomes of thoracic damage control surgery (TDCS). This study aimed to describe the characteristics and outcomes of patients undergoing TDCS.
• Khurshid, M., Hejazi, O., Spencer, A., Nelson, A., Stewart, C., Colosimo, C., Ditillo, M., Matthews, M., Magnotti, L., & Joseph, B. (2024). A little goes a long way: A comparison of enterolithotomy versus single-stage cholecystectomy in the management of gallstone ileus. Journal of Trauma and Acute Care Surgery. doi:10.1097/TA.0000000000004497
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  INTRODUCTION Gallstone ileus is an infrequent complication of cholelithiasis with no specific guidelines for its management. This study aims to compare the outcomes of patients with gallstone ileus managed with both enterolithotomy with cholecystectomy (EL-CCY) versus those managed with enterolithotomy (EL) only. METHODS In this retrospective analysis of 2011-2017 Nationwide Readmissions Database, all patients with an index admission diagnosis of gallstone ileus were included. Patients were stratified based on the type of intervention received for gallstone ileus into those who underwent EL-CCY and those who underwent EL alone and compared. Primary outcomes were in-hospital complications (surgical site infections, sepsis, pneumonia, cardiac arrest, deep vein thrombosis, intestinal obstruction) and mortality. Secondary outcomes were hospital length of stay, hospital costs, and readmissions rate and cause of readmissions. Multivariable logistic regression analysis was performed. RESULTS A total of 1,960 patients were identified. The mean age was 67 years and 67% were female. Two hundred eighty-nine patients (14.7%) were managed with EL-CCY, whereas 1,671 patients (85.3%) underwent EL only. Overall, the readmission rate was 4.8%, whereas mortality was 4.2%. There was no significant difference between groups in terms of index-admission complications (24.8% vs. 21.7%, p = 0.415), mortality (6.2% vs. 3.9%, p = 0.068), rates of readmission (3.5% vs. 5.1%, p = 0.22), and cause of readmission (p > 0.05). Enterolithotomy and cholecystectomy group had significantly longer hospital length of stay (10 vs. 8 days, p < 0.001) and median hospital costs ($70,959 vs. $52,147, p < 0.001). On multivariable logistic regression analysis, female sex was a predictor of undergoing EL-CCY, whereas increasing age and higher grade of all-patient redefined diagnosis-related groups risk of mortality were independently associated with lower odds of undergoing EL-CCY. CONCLUSION Our findings suggest no difference between EL compared with EL-CCY in terms of complications, readmissions, and mortality. However, patients managed with EL-CCY had a longer hospital stay and higher hospital costs compared with EL. Further prospective studies are needed to validate these findings and develop management protocols for gallstone ileus.
• Khurshid, M., Yang, A., Hosseinpour, H., Colosimo, C., Hejazi, O., Spencer, A., Bhogadi, S., Ditillo, M., Magnotti, L., & Joseph, B. (2024). Final Lifelines: The Implications and Outcomes of Thoracic Damage Control Surgeries. Journal of Surgical Research, 301. doi:10.1016/j.jss.2024.06.031
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  Introduction: There is a lack of data on the outcomes of thoracic damage control surgery (TDCS). This study aimed to describe the characteristics and outcomes of patients undergoing TDCS. Methods: This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2021). All trauma patients who underwent emergency thoracotomy and packing with temporary closure were included. Patients were stratified based on the age groups (pediatric [
• Li, C., Guo, M., Karimuddin, A., Guo, M., Li, C., Karimuddin, A., Sutherland, J., Huo, B., McKechnie, T., Ortenzi, M., Lee, Y., Antoniou, S., Mayol, J., Ahmed, H., Boudreau, V., Ramji, K., Eskicioglu, C., de Jager, P., Urbach, D., , Poole, M., et al. (2024). 2024 Canadian Surgery Forum: Sept. 25-28, 2024. Canadian journal of surgery. Journal canadien de chirurgie, 67(6suppl2), S77-S108.
• Magnotti, L. J., Bhogadi, S. K., Anand, T., Stewart, C., Colosimo, C., Spencer, A. L., Nelson, A., & Joseph, B. (2024). Less Is More: Dissecting Trauma Centers by Procedural Volume. Annals of surgery, 280(4), 667-675.
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  This study aims to examine the relationship between procedural volume and annual trauma volume (ATV) of ACS Level I trauma centers (TC).
• O'Connor, D., Hejazi, O., Colosimo, C., Stewart, C., Hosseinpour, H., Khurshid, M., Nelson, A., Joseph, B., Bhogadi, S., Anand, T., Spencer, A., & Magnotti, L. (2024). Role of endovascular management on outcomes in patients with traumatic inferior vena cava injuries. American Journal of Surgery, 238. doi:10.1016/j.amjsurg.2024.115836
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  Introduction: The aim of this study was to examine the association between the injury mechanism and repair type with outcomes in patients with traumatic inferior vena cava injuries. Methods: This is a retrospective analysis of the ACS-TQIP database (2017–2020), including patients with traumatic IVC injuries. Patients were stratified by injury mechanism and type of repair and compared. Results: Out of 1334 patients, 5 ​% underwent endovascular repair while 95 ​% had an open procedure. Overall, 74.7 ​% sustained a penetrating injury. On multivariable regression analysis, the type of repair was not associated with mortality and morbidity for patients with penetrating injuries. However, among patients with blunt injuries, endovascular repair was associated with lower odds of in-hospital mortality (aOR:0.35, p ​= ​0.020) and non-venous thromboembolism (VTE) morbidity (aOR:0.41, p ​= ​0.015), and higher odds of VTE complications (aOR:6.74, p ​< ​0.001). Conclusions: Although the type of repair did not impact morbidity and mortality in patients with penetrating injuries, endovascular repair was identified as the only modifiable predictor of reduced non-VTE morbidity and mortality in patients with blunt injuries.
• O'Connor, D., Hejazi, O., Colosimo, C., Stewart, C., Hosseinpour, H., Khurshid, M., Nelson, A. C., Joseph, B., Bhogadi, S. K., Anand, T., Spencer, A. L., & Magnotti, L. J. (2024). Role of endovascular management on outcomes in patients with traumatic inferior vena cava injuries. American journal of surgery, 238, 115836.
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  The aim of this study was to examine the association between the injury mechanism and repair type with outcomes in patients with traumatic inferior vena cava injuries.
• Otaibi, B. W., Bhogadi, S. K., Khurshid, M. H., Stewart, C., Hosseinpour, H., Spencer, A. L., Hejazi, O., Nelson, A., Magnotti, L. J., & Joseph, B. (2024). Endovascular Versus Open Repair in Adolescent Patients With Difficult-to-Access Vascular Injuries. The Journal of surgical research, 302, 385-392.
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  Management of subclavian artery injuries (SAI) and iliac artery injuries (IAI) in adolescent trauma patients poses a considerable challenge due to their complex anatomical locations. The aim of our study was to determine the association between the injury mechanism and type of repair with the outcomes of patients with traumatic SAI and IAI.
• Otaibi, B., Bhogadi, S., Khurshid, M., Stewart, C., Hosseinpour, H., Spencer, A., Hejazi, O., Nelson, A., Magnotti, L., & Joseph, B. (2024). Endovascular Versus Open Repair in Adolescent Patients With Difficult-to-Access Vascular Injuries. Journal of Surgical Research, 302. doi:10.1016/j.jss.2024.07.068
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  Introduction: Management of subclavian artery injuries (SAI) and iliac artery injuries (IAI) in adolescent trauma patients poses a considerable challenge due to their complex anatomical locations. The aim of our study was to determine the association between the injury mechanism and type of repair with the outcomes of patients with traumatic SAI and IAI. Methods: In this retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database2017-2020, adolescent (
• Safdar, M., Colosimo, C., Khurshid, M. H., Spencer, A. L., Hejazi, O., Castanon, L., Hosseinpour, H., Magnotti, L. J., Bhogadi, S. K., & Joseph, B. (2024). Drugs, Delirium, and Trauma: Substance Use and Incidence of Delirium After Traumatic Brain Injury. The Journal of surgical research, 301, 45-53.
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  There is a paucity of data on the effect of preinjury substance (alcohol, drugs) abuse on the risk of delirium in patients with traumatic brain injury (TBI). This study aimed to assess the incidence of delirium among patients with blunt TBI in association with different substances.
• Safdar, M., Colosimo, C., Khurshid, M., Spencer, A., Hejazi, O., Castanon, L., Hosseinpour, H., Magnotti, L., Bhogadi, S., & Joseph, B. (2024). Drugs, Delirium, and Trauma: Substance Use and Incidence of Delirium After Traumatic Brain Injury. Journal of Surgical Research, 301. doi:10.1016/j.jss.2024.05.042
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  Introduction: There is a paucity of data on the effect of preinjury substance (alcohol, drugs) abuse on the risk of delirium in patients with traumatic brain injury (TBI). This study aimed to assess the incidence of delirium among patients with blunt TBI in association with different substances. Methods: We analyzed the 2020 American College of Surgeons–Trauma Quality Improvement Program. We included all adult (≥18 y) patients with blunt TBI who had a recorded substance (drugs and alcohol) screening. Our primary outcome was the incidence of delirium. Results: A total of 72,901 blunt TBI patients were identified. The mean (standard deviation) age was 56 (20) years and 68.0% were males. The median (interquartile range) injury severity score was 17 (10-25). Among the study population, 23.1% tested positive for drugs (Stimulants: 3.0%; Depressants: 2.9%, hallucinogens: 5.1%, Cannabinoids: 13.4%, TCAs: 0.1%), and 22.8% tested positive for Alcohol. Overall, 1856 (2.5%) experienced delirium. On univariate analysis, patients who developed delirium were more likely to have positive drug screening results. On multivariable regression analyses, positive screen tests for isolated stimulants (adjusted odds ratio [aOR]: 1.340, P = 0.018), tricyclic antidepressants (aOR: 3.107, P = 0.019), and cannabinoids (aOR: 1.326, P ≤ 0.001) were independently associated with higher odds of developing delirium. Conclusions: Nearly one-fourth of adult patients with blunt TBI had an initial positive substance screening test. Patients with positive results for isolated stimulants, tricyclic antidepressants, and cannabinoids were at a higher risk of developing delirium, whereas this association was not evident with other drugs and alcohol-positive tests. These findings emphasize the need for early drug screening in TBI patients and close monitoring of patients with positive screening tests.
• Spaniolas, K., Pryor, A., Stefanidis, D., Giannopoulos, S., Miller, P. R., Spencer, A. L., Docimo, S., DuCoin, C., Ross, S. W., Schiffern, L., Reinke, C., Sherrill, W., Nahmias, J., Manasa, M., Kindel, T., Wijekulasooriyage, D., Cardinali, L., Di Saverio, S., Yang, J., & Liao, Y. (2024). Multisociety research collaboration: timing of cholecystectomy following cholecystostomy drainage for acute cholecystitis. Surgical endoscopy, 38(10), 6053-6059.
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  Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events.
• Spaniolas, K., Pryor, A., Stefanidis, D., Giannopoulos, S., Miller, P., Spencer, A., Docimo, S., DuCoin, C., Ross, S., Schiffern, L., Reinke, C., Sherrill, W., Nahmias, J., Manasa, M., Kindel, T., Wijekulasooriyage, D., Cardinali, L., Di Saverio, S., Yang, J., & Liao, Y. (2024). Multisociety research collaboration: timing of cholecystectomy following cholecystostomy drainage for acute cholecystitis. Surgical Endoscopy, 38(10). doi:10.1007/s00464-024-11145-7
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  Background: Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events. Methods: This was a retrospective (2018–2020) multicenter study at 8 participating hospital systems of adult patients with AC, managed with PC and interval cholecystectomy. Demographics, comorbidities, treatment details, and outcomes were examined. Patients were grouped based on quartiles for timing of surgery after PC (< 7, 7–9, 10–13, > 13 weeks). The primary outcome was a composite endpoint of bile duct injury, reoperation, readmission, image-guided intervention, endoscopic intervention, conversion to open surgery, or death. Results: There were 188 patients with a median age of 66 years with AC classified as mild (41%), moderate (47%), and severe (12%). Median days from PC to surgery were 65 (Q1 = 48, Q3 = 91). Laparoscopic cholecystectomy (89.9%) was the most commonly planned approach (robotic 6.4%, 3.7% open) and 28 (14.9%) were converted to open. The composite endpoint was reported in 51 patients (27.1%). A biliary injury occurred in 7 (3.7%) patients. Time to surgery and intraoperative drain placement were independently associated with the composite outcome. Cholecystectomy within 7 weeks of PC was associated with decreased risk (OR = 0.36, 95% CI 0.13–0.97) of the composite endpoint, compared to patients undergoing surgery > 13 weeks after PC. Conclusion: Timing of surgery following PC was associated with procedural outcomes. Patients undergoing surgery before 7 weeks experienced significantly less morbidity than patients having delayed cholecystectomy. These results should be considered in patient selection and management after PC.
• Spencer, A. L., Hosseinpour, H., Nelson, A., Hejazi, O., Anand, T., Khurshid, M. H., Ghaedi, A., Bhogadi, S. K., Magnotti, L. J., & Joseph, B. (2024). Predicting the time of mortality among older adult trauma patients: Is frailty the answer?. American journal of surgery, 237, 115768.
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  This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization.
• Spencer, A., Hosseinpour, H., Nelson, A., Hejazi, O., Anand, T., Khurshid, M., Ghaedi, A., Bhogadi, S., Magnotti, L., & Joseph, B. (2024). Predicting the time of mortality among older adult trauma patients: Is frailty the answer?. American Journal of Surgery, 237. doi:10.1016/j.amjsurg.2024.05.009
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  Introduction: This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization. Methods: We performed a 3-year (2017–2019) analysis of ACS-TQIP. We included all older adult (age ≥65 years) trauma patients. Patients were stratified into two groups (Frail vs. Non-Frail). Outcomes were acute (1 week) mortality. Results: A total of 1,022,925 older adult trauma patients were identified, of which 19.7 ​% were frail. The mean(SD) age was 77(8) years and 57.4 ​% were female. Median[IQR] ISS was 9[4–10] and both groups had comparable injury severity (p ​= ​0.362). On multivariable analysis, frailty was not associated with acute (aOR 1.034; p ​= ​0.518) and early (aOR 1.190; p ​= ​0.392) mortality, while frail patients had independently higher odds of intermediate (aOR 1.269; p ​= ​0.042) and late (aOR 1.835; p ​< ​0.001) mortality. On sub-analysis, our results remained consistent in mild, moderate, and severely injured patients. Conclusion: Frailty is an independent predictor of mortality in older adult trauma patients who survive the initial 3 days of admission, regardless of injury severity.
• Terrani, K. F., Bhogadi, S. K., Hosseinpour, H., Spencer, A. L., Alizai, Q., Colosimo, C., Nelson, A., Castanon, L., Magnotti, L. J., & Joseph, B. (2024). What Is Going on in Our Schools? Review of Injuries Among School Children Across the United States. The Journal of surgical research, 295, 310-317.
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  Children spend most of their time at school and participate in many activities that have the potential for causing injury. This study aims to describe the nationwide epidemiology of pediatric trauma sustained in school settings in the United States.
• Terrani, K., Bhogadi, S., Hosseinpour, H., Spencer, A., Alizai, Q., Colosimo, C., Nelson, A., Castanon, L., Magnotti, L., & Joseph, B. (2024). What Is Going on in Our Schools? Review of Injuries Among School Children Across the United States. Journal of Surgical Research, 295. doi:10.1016/j.jss.2023.11.019
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  Introduction: Children spend most of their time at school and participate in many activities that have the potential for causing injury. This study aims to describe the nationwide epidemiology of pediatric trauma sustained in school settings in the United States. Methods: In the 3-y analysis of 2017-2019 American College of Surgeons-Trauma Quality Program, all pediatric trauma patients (≤18 y) injured in a school setting were included and stratified based on place of injury, into elementary, middle, and high school (HS) groups. Descriptive statistics and multivariable logistic regression analysis were performed to identify the independent predictors of intentional injuries. Results: 23,215 pediatric patients were identified, of which 15,264 patients were injured at elementary (57.6%), middle (17.5%), and high (25%) schools. The mean age was 9.5 y, 66.9% were male, 63.9% were white, the median injury severity score was 2 [1-4], and 95.6% had a blunt injury. Elementary school students were more likely to sustain falls (85%) and humerus fractures (43%) whereas HS students were more likely to be injured by assaults (17%). Overall, 7% of the students sustained intentional injuries. On multivariable logistic regression, male gender (odds ratio [OR] 1.54), Black race (OR 2.94), American Indian race (OR 1.88), Hispanic ethnicity (OR 1.77), positive drug screen (OR 4.9), middle (OR 5.2), and HSs (OR 10.6) were identified as independent predictors of intentional injury (all P < 0.01). Conclusions: Injury patterns vary across elementary, middle, and HSs. Racial factors appear to influence intentional injuries along with substance abuse. Further studies to understand these risk factors and efforts to reduce school injuries are warranted to provide a safe learning environment for children.
• Zambetti, B., Nelson, A., Hosseinpour, H., Anand, T., Colosimo, C., Spencer, A., Stewart, C., Bhogadi, S., Hejazi, O., Joseph, B., & Magnotti, L. (2024). The optimal management of blunt aortic injury in the young. American Journal of Surgery, 237. doi:10.1016/j.amjsurg.2024.115943
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  Background: Blunt aortic injury (BAI) is relatively uncommon in the pediatric population. The goal of this study was to examine the management of BAI in both children and adolescents, using a large national dataset. Methods: Patients (1–19 years of age) with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 14-years. Patients were stratified by age group (children [ages 1–9] and adolescents [ages 10–19]) and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in adolescents with BAI. Results: Adolescents undergoing TEVAR had similar morbidity (16.8 vs 12.6 ​%, p ​= ​0.057) and significantly reduced mortality (2.1 vs 14.4 ​%, p ​< ​0.0001) compared to those adolescents managed non-operatively. MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (OR 0.138; 95%CI 0.059–0.324, p ​< ​0.0001). Conclusions: BAI leads to significant morbidity and mortality for both children and adolescents. For pediatric patients with BAI, children may be safely managed non-operatively, while an endovascular repair may improve outcomes for adolescents.
• Alizai, Q., Anand, T., Bhogadi, S. K., Nelson, A., Hosseinpour, H., Stewart, C., Spencer, A. L., Colosimo, C., Ditillo, M., & Joseph, B. (2023). From surveillance to surgery: The delayed implications of non-operative and operative management of pancreatic injuries. American journal of surgery, 226(5), 682-687.
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  Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries.
• Alizai, Q., Arif, M. S., Colosimo, C., Hosseinpour, H., Spencer, A. L., Bhogadi, S. K., Nelson, A., Anand, T., Ditillo, M., & Joseph, B. (2023). Beyond the short-term relief: Outcomes of geriatric rib fracture patients receiving paravertebral nerve blocks and epidural analgesia. Injury, 111184.
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  Adequate pain control is a critical component of rib fracture management. Our study aimed to evaluate the in-hospital and post-discharge outcomes of geriatric rib fracture patients who received paravertebral nerve block (PVNB) versus epidural analgesia (EA) on a national level.
• Alizai, Q., Colosimo, C., Hosseinpour, H., Stewart, C., Bhogadi, S. K., Nelson, A., Spencer, A. L., Ditillo, M., Magnotti, L. J., Joseph, B., & , A. F. (2023). It's Not All Black and White: The Effect of Increasing Severity of Frailty on Outcomes of Geriatric Trauma Patients. The journal of trauma and acute care surgery.
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  Frailty is associated with poor outcomes in trauma patients. However, the spectrum of physiologic deficits, once a patient is identified as frail, is unknown. The aim of this study was to assess the dynamic association between increasing frailty and outcomes among frail geriatric trauma patients.
• Avila, M., Bhogadi, S. K., Nelson, A., Hosseinpour, H., Ditillo, M., Akl, M., Anand, T., Spencer, A. L., Magnotti, L. J., & Joseph, B. (2023). The long-term risks of venous thromboembolism among non-operatively managed spinal fracture patients: A nationwide analysis. American journal of surgery, 225(6), 1086-1090.
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  Long-term readmission data for venous thromboembolism (VTE) after spinal fractures is limited. We aimed to evaluate the 1-month and 6-month VTE readmission rates in non-operatively managed traumatic spinal fractures.
• Bhogadi, S. K., Alizai, Q., Colosimo, C., Spencer, A. L., Stewart, C., Nelson, A., Ditillo, M., Castanon, L., Magnotti, L. J., Joseph, B., , B. M., , A. A., Dultz, L., Black, G., Campbell, M., Berndtson, A. E., Costantini, T., Kerwin, A., Skarupa, D., , Burruss, S., et al. (2023). Not all traumatic brain injury patients on preinjury anticoagulation are the same. American journal of surgery, 226(6), 785-789.
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  Prognostic significance of different anticoagulants in TBI patients remains unanswered. We aimed to compare effects of different anticoagulants on outcomes of TBI patients.
• Bhogadi, S. K., Magnotti, L. J., Hosseinpour, H., Anand, T., El-Qawaqzeh, K., Nelson, A., Colosimo, C., Spencer, A. L., Friese, R., & Joseph, B. (2023). The final decision among the injured elderly, to stop or to continue? Predictors of withdrawal of life supporting treatment. The journal of trauma and acute care surgery, 94(6), 778-783.
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  There is a paucity of data on factors that influence the decision regarding withdrawal of life supporting treatment (WLST) in geriatric trauma patients. We aimed to identify predictors of WLST in geriatric trauma patients.
• Bhogadi, S. K., Nelson, A., El-Qawaqzeh, K., Spencer, A. L., Hosseinpour, H., Castanon, L., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Does preinjury anticoagulation worsen outcomes among traumatic hemothorax patients? A nationwide retrospective analysis. Injury, 54(9), 110850.
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  Up to a quarter of all traumatic deaths are due to thoracic injuries. Current guidelines recommend consideration of evacuation of all hemothoraces with tube thoracostomy. The aim of our study was to determine the impact of pre-injury anticoagulation on outcomes of traumatic hemothorax patients.
• Bhogadi, S. K., Stewart, C., El-Qawaqzeh, K., Colosimo, C., Hosseinpour, H., Nelson, A., Castanon, L., Spencer, A. L., Magnotti, L. J., & Joseph, B. (2023). Local Antibiotic Therapy for Open Long Bone Fractures: Appropriate Prophylaxis or Unnecessary Exposure for the Orthopedic Trauma Patient?. Military medicine, 188(Suppl 6), 407-411.
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  Prophylactic local antibiotic therapy (LAbT) to prevent infection in open long bone fracture (OLBF) patients has been in use for many decades despite lack of definitive evidence confirming a beneficial effect. We aimed to evaluate the effect of LAbT on outcomes of OLBF patients on a nationwide scale.
• Castanon, L., Bhogadi, S. K., Anand, T., Hosseinpour, H., Nelson, A., Colosimo, C., Spencer, A. L., Gries, L., Ditillo, M., & Joseph, B. (2023). The Association Between the Timing of Initiation of Pharmacologic Venous Thromboembolism Prophylaxis with Outcomes in Burns Patients. Journal of burn care & research : official publication of the American Burn Association, 44(6), 1311-1315.
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  Hospitalized burn patients are at increased risk for venous thromboembolism (VTE). Guidelines regarding thromboprophylaxis in burn patients are unclear. This study aims to compare the outcomes of early versus late thromboprophylaxis initiation in burn patients. In this 3-year analysis of 2017-2019 ACS-TQIP, adult(18-64years) burn patients were identified after applying inclusion/exclusion criteria and stratified based on timing of initiation of VTE prophylaxis: Early(24 hours). Outcomes were deep venous thrombosis(DVT), pulmonary embolism(PE), unplanned return to operating room (OR), unplanned intensive care unit (ICU) admission, post-prophylaxis packed red blood cells (PRBC) transfusion, and mortality. Nine thousand two hundred and seventy-two patients were identified. Overall, median age was 41years, 71.5% were male, and median[IQR] injury severity score was 3[1-8]. 53% had second-degree burns, and 80% had less than 40% of total body surface area affected. Median time to thromboprophylaxis initiation was 11[6-20.6]hours. Overall VTE rate was 0.9% (DVT-0.7%, PE-0.2%). On univariable analysis, early prophylaxis group had lower rates of DVT(0.6% vs 1.1%, P = .025), and PE(0.1% vs 0.6%, P < .001). On multivariable regression, late prophylaxis was associated with 1.8 times higher odds of DVT (aOR = 1.8, 95% CI = 1.04-3.11, P = .03), 4.8 times higher odds of PE(aOR = 4.8, 95% CI = 1.9-11.9, P 
• El-Qawaqzeh, K., Anand, T., Alizai, Q., Colosimo, C., Hosseinpour, H., Spencer, A., Ditillo, M., Magnotti, L. J., Stewart, C., & Joseph, B. (2024). Trauma in the Geriatric and the Super-Geriatric: Should They Be Treated the Same?. The Journal of surgical research, 293, 316-326.
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  There is paucity of studies comparing the characteristics of trauma in geriatrics and super-geriatrics. We aimed to explore the injury characteristics and outcomes of older adult trauma patients on a nationwide scale.
• El-Qawaqzeh, K., Magnotti, L. J., Hosseinpour, H., Nelson, A., Spencer, A. L., Anand, T., Bhogadi, S. K., Alizai, Q., Ditillo, M., & Joseph, B. (2023). Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes?. Injury, 110972.
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  It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes.
• Hosseinpour, H., Anand, T., Bhogadi, S. K., Colosimo, C., El-Qawaqzeh, K., Spencer, A. L., Castanon, L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Emergency Department Shock Index Outperforms Prehospital and Delta Shock Indices in Predicting Outcomes of Trauma Patients. The Journal of surgical research, 291, 204-212.
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  Multiple shock indices (SIs), including prehospital, emergency department (ED), and delta (ED SI - Prehospital SI) have been developed to predict outcomes among trauma patients. This study aims to compare the predictive abilities of these SIs for outcomes of polytrauma patients on a national level.
• Hosseinpour, H., El-Qawaqzeh, K., Magnotti, L. J., Bhogadi, S. K., Ghneim, M., Nelson, A., Spencer, A. L., Colosimo, C., Anand, T., Ditillo, M., & Joseph, B. (2023). The unexpected paradox of geriatric traumatic brain injury outcomes: Uncovering racial and ethnic disparities. American journal of surgery, 226(2), 271-277.
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  Healthcare disparities have always challenged surgical care in the US. We aimed to assess the influence of disparities on cerebral monitor placement and outcomes of geriatric TBI patients.
• Hosseinpour, H., Magnotti, L. J., Bhogadi, S. K., Anand, T., El-Qawaqzeh, K., Ditillo, M., Colosimo, C., Spencer, A., Nelson, A., & Joseph, B. (2023). Time to Whole Blood Transfusion in Hemorrhaging Civilian Trauma Patients: There Is Always Room for Improvement. Journal of the American College of Surgeons, 237(1), 24-34.
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  Whole blood (WB) is becoming the preferred product for the resuscitation of hemorrhaging trauma patients. However, there is a lack of data on the optimum timing of receiving WB. We aimed to assess the effect of time to WB transfusion on the outcomes of trauma patients.
• Hosseinpour, H., Magnotti, L. J., Bhogadi, S. K., Colosimo, C., El-Qawaqzeh, K., Spencer, A. L., Anand, T., Ditillo, M., Nelson, A., & Joseph, B. (2023). Interfacility transfer of pediatric trauma patients to higher levels of care: The effect of transfer time and level of receiving trauma center. The journal of trauma and acute care surgery, 95(3), 383-390.
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  Interfacility transfer of pediatric trauma patients to pediatric trauma centers (PTCs) after evaluation in nontertiary centers is associated with improved outcomes. We aimed to assess the outcomes of transferred pediatric patients based on their severity of the injury, transfer time, and level of receiving PTCs.
• Hosseinpour, H., Nelson, A., Bhogadi, S. K., Spencer, A. L., Alizai, Q., Colosimo, C., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Delayed versus early hepatic resection among patients with severe traumatic liver injuries undergoing damage control laparotomy. American journal of surgery, 226(6), 823-828.
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  We aimed to assess the effect of time to hepatic resection on the outcomes of patients with high-grade liver injuries who underwent damage control laparotomy (DCL).
• Litmanovich, B., Alizai, Q., Stewart, C., Hosseinpour, H., Nelson, A., Bhogadi, S. K., Colosimo, C., Spencer, A. L., Ditillo, M., & Joseph, B. (2024). Outcomes of Geriatric Burn Patients Presenting to the Trauma Service: How Does Frailty Factor in?. The Journal of surgical research, 293, 327-334.
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  Frailty has been known to negatively affect the outcomes of geriatric trauma patients. However, there is a lack of data on the effect of frailty on the outcomes of geriatric trauma patients with concomitant burn injuries. The aim of our study was to compare the outcomes of frail versus nonfrail geriatric trauma patients with concomitant burn injuries.
• Nelson, A. C., Bhogadi, S. K., Hosseinpour, H., Stewart, C., Anand, T., Spencer, A. L., Colosimo, C., Magnotti, L. J., & Joseph, B. (2023). There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis. Journal of the American College of Surgeons, 237(5), 712-718.
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  Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP).
• Schellenberg, M., Owattanapanich, N., Emigh, B., Van Gent, J. M., Egodage, T., Murphy, P. B., Ball, C. G., Spencer, A. L., Vogt, K. N., Keeley, J. A., Doris, S., Beiling, M., Donnelly, M., Ghneim, M., Schroeppel, T., Bradford, J., Breinholt, C. S., Coimbra, R., Berndtson, A. E., , Anding, C., et al. (2023). When Is It Safe to Start VTE Prophylaxis after Blunt Solid Organ Injury? A Prospective AAST Multi-Institutional Trial. The journal of trauma and acute care surgery.
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  The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests VTEp ≤48 h is safe and effective. This study was undertaken to validate this clinical practice.
• Spencer, A. L., Miller, P. R., Russell, G. B., Cornea, I., & Marterre, B. (2023). Timing is everything: Early versus late palliative care consults in trauma. The journal of trauma and acute care surgery, 94(5), 652-658.
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  The incorporation of dedicated palliative care (PC) services in the care of the critically injured trauma patient is not yet universal. Preexisting data demonstrate both economic and clinical value of PC consults, yet patient selection and optimal timing of these consults are poorly defined, possibly leading to underutilization of PC services. Prior studies in geriatric patients have shown benefits of PC when PC clinicians are engaged earlier during hospitalization. We aim to compare hospitalization metrics of early versus late PC consultation in trauma patients.
• Stettler, G. R., Ganapathy, A. S., Bosley, M. E., Spencer, A. L., Neff, L. P., Nunn, A. M., & Miller, P. R. (2023). Win or lose, nighttime transcystic laparoscopic common bile duct exploration is a win. Trauma surgery & acute care open, 8(1), e001045.
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  Although controversial, recent data suggest nighttime versus daytime laparoscopic cholecystectomy (LC) have comparable outcomes. Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis decreases length of stay (LOS) as compared with LC with endoscopic retrograde cholangiopancreatography (ERCP) but increases case complexity/time. The influence of time of day on LCBDE outcomes has not been evaluated. Our aim was to examine outcomes and LOS for nighttime (PM) compared with daytime LC+LCBDE (DAY).
• Ganapathy, A. S., Bosley, M. E., Spencer, A. L., Evangelista, M. E., Miller, P. R., Nunn, A. M., & Neff, L. P. (2022). Liver Function Tests after Laparoscopic Common Bile Duct Exploration Are Not Reliable. Journal of the American College of Surgeons. doi:10.1097/01.xcs.0000893584.43821.4a
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  INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) to manage choledocholithiasis at the time of cholecystectomy (LC+LCBDE) is gaining traction and requires examination of the role of postoperative laboratory data to guide clinical care. We examined postoperative liver function test (LFT) trends in the context of successful and failed LCBDE. METHODS: Retrospective review of all adult emergency general surgery (EGS) patients undergoing LCBDE over a 3-year period. Failed LC+LCBDE was defined as the subsequent need for endoscopic retrograde cholangiopancreatography (ERCP) for duct clearance. Postoperative LFTs from both successful and failed LCBDE attempts were analyzed. Postoperative laboratory values from all LC+LCBDE were classified as increased, decreased, or unchanged from preoperative. Procedure outcomes were analyzed. RESULTS: Sixty patients underwent LCBDE. Ten patients were excluded for not having preoperative laboratory tests or any postoperative laboratory tests. Thirty-three of the remaining 50 patients had 2 sets of postoperative laboratory tests. In patients who underwent successful LCBDE, there was no statistical difference (p > 0.05) between the preoperative and the 1st postoperative or 2nd postoperative laboratory tests regarding total bilirubin, aspartate/alanine aminotransferase, or alkaline phosphatase. For patients who had an unsuccessful LCBDE and required postoperative ERCP, this was also true. No patients with successful LCBDE with increased postoperative laboratory tests had complication. CONCLUSION: Despite the LCBDE outcome, postoperative laboratory tests do not provide reliable prognostication as would be expected in the given clinical context. Contrast flow into the duodenum and surgeon judgment are better indicators of duct clearance. It is safe to discharge patients without LFT after successful and uneventful LCBDE.
• Spencer, A. L., Nunn, A. M., Miller, P. R., Russell, G. B., Carmichael, S. P., Neri, K. E., & Marterre, B. (2022). The value of compassion: Healthcare savings of palliative care consults in trauma. Injury.
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  The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear.
• Farrell, M., Spencer, A., Gbadebo, A., Zhang, Z., & Halbert, C. (2019). Relationship of Hemorrhagic Complications with Perioperative Blood Pressure in Bariatric Surgery. The American surgeon, 85(5), 561-562.

Proceedings Publications

• Alizai, Q., Colosimo, C., Hosseinpour, H., Stewart, C., Bhogadi, S., Nelson, A., Spencer, A., Ditillo, M., Magnotti, L., Joseph, B., Amos, J., Teichman, A., Whitmill, M., Burruss, S., Dunn, J., Najafi, K., Godat, L., Enniss, T., Shoultz, T., , Egodage, T., et al. (2024). It is not all black and white: The effect of increasing severity of frailty on outcomes of geriatric trauma patients. In Journal of Trauma and Acute Care Surgery.
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  BACKGROUND Frailty is associated with poor outcomes in trauma patients. However, the spectrum of physiologic deficits, once a patient is identified as frail, is unknown. The aim of this study was to assess the dynamic association between increasing frailty and outcomes among frail geriatric trauma patients. METHODS This is a secondary analysis of the American Association of Surgery for Trauma Frailty Multi-institutional Trial. Patients 65 years or older presenting to one of the 17 trauma centers over 3 years (2019-2022) were included. Frailty was assessed within 24 hours of presentation using the Trauma-Specific Frailty Index (TSFI) questionnaire. Patients were stratified by TSFI score into six groups: nonfrail (
• Magnotti, L., Bhogadi, S., Anand, T., Stewart, C., Colosimo, C., Spencer, A., Nelson, A., & Joseph, B. (2024). Less Is More: Dissecting Trauma Centers by Procedural Volume. In Annals of Surgery..
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  Objective: This study aims to examine the relationship between procedural volume and annual trauma volume (ATV) of ACS Level I trauma centers (TC). Background: Although ATV is a hard criterion for TC verification, importance of procedural interventions as a potential quality indicator is understudied. Methods: Patients managed at ACS level I TCs were identified from ACS-TQIP 2017-2021. TCs were identified using facility keys and stratified into quartiles based on ATV into low, low-medium, medium-high, and high volume. TCs were also stratified into tertiles [low (LV), medium (MV), high (HV)] based on procedural volume by assessing annual number of laparotomies, thoracotomies, craniotomies/craniectomies, angioembolizations, vascular repairs, and long bone fixations performed at each center. The Cohen κ statistic was used to assess concordance between ATV and procedural volume. Results: A total of 182 Level I TCs were identified: 76 low, 47 low-medium, 35 high-medium, and 24 high volume. Long bone fixation, laparotomy, and craniotomy/craniectomy were the most performed procedures with a median of 65, 59, and 46 cases/center/year, respectively. Overall, 31% of HV laparotomy centers, 31% of HV thoracotomy centers, 22% of HV craniotomy/craniectomy centers, 22% of HV vascular repair centers, 32% of HV long bone fixation centers, and 33% of HV angioembolization centers contributed to the overall number of low-medium and low-volume TCs. The Cohen κ statistic demonstrated poor concordance between ATV and procedural volumes for all procedures (overall procedural volume - κ=0.378, laparotomy - κ=0.270, thoracotomy - κ=0.202, craniotomy/craniectomy - κ=0.394, vascular repair - κ=0.298, long bone fixation - κ=0.277, angioembolization - κ=0.286). Conclusions: ATV does not reflect the procedural interventions performed. Combination of procedural and ATV may provide a more accurate picture of the clinical experience at any given TC. Level of Evidence: Level III.
• Schellenberg, M., Owattanapanich, N., Emigh, B., Van Gent, J., Egodage, T., Murphy, P., Ball, C., Spencer, A., Vogt, K., Keeley, J., Doris, S., Beiling, M., Donnelly, M., Ghneim, M., Schroeppel, T., Bradford, J., Breinholt, C., Coimbra, R., Berndtson, A., , Anding, C., et al. (2024). When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial. In Journal of Trauma and Acute Care Surgery.
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  BACKGROUND: The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice. METHODS: Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate andmultivariable analyses compared outcomes. RESULTS: In total, 1,173 patients satisfied the study criteriawith 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024)when compared with LateVTEp patients (n = 301 [26%]). Late VTEp was independently associatedwith VTE (odd ratio, 2.251; p = 0.046). CONCLUSION: Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤ 48 hours is therefore safe and effective and should be the standard of care for patientswith blunt solid organ injury.