Michael Ditillo

Interests

Research

Frailty and geriatric trauma outcomes, post-cardiac arrest hypothermia in surgical/trauma patients, reversal of coagulopathy in trauma, and delirium in trauma and surgical patients.

Teaching

Dr. Ditillo’s clinical interests are in geriatric trauma, post-cardiac arrest hypothermia, coagulopathy in trauma, and hemostatic resuscitation.

Courses

Scholarly Contributions

Chapters

• Ditillo, M. (2014). Appendicitis. In Geriatric Trauma and Emergency Care. New York: Springer Publishing.
• Chi, A., & Ditillo, M. (2013). Nutritional management of gastroenterocutaneous fistulas. In Surgery of Complex Abdominal Wall Defects. doi:10.1007/978-1-4614-6354-2_23
  More info

  Despite significant improvements in medical and surgical treatments of gastroenterocutaneous fistulas (ECFs), they remain a significant cause of morbidity and mortality for patients who develop them. A hypermetabolic response and profound disturbances in fluid and electrolyte levels, leading to dehydration, hyponatraemia, hypokalemia, and metabolic acidosis, are common, making this patient population a unique subgroup of critically ill patients vulnerable to further decline in nutritional status. In general, medical treatment and stabilization precede attempts at surgical intervention and remain a hallmark of therapy for ECFs. The most challenging aspect of ECF management is nutritional repletion because there is no standard protocol, and each patient and case is unique. The management requires patient- as well as fistula-specific factors to be considered for optimizing the best treatment regimen. Currently, there are no well-established, evidence-based clinical guidelines for managing the medications and nutrition care of these patients. Although it is often difficult and sometimes impossible to provide adequate enteral nutrition in the presences of an ECF, nutritional support should be implemented whenever possible. Many questions have been answered; however, there is no uniformity to these answers. This chapter reviews the roles of enteral and supplemental parenteral nutrition, somatostatin, and immune-modulating nutritional supplementation.
• Ditillo, M., & Davis, K. A. (2013). Appendicitis. In Appendicitis. doi:10.1007/978-1-4614-8501-8_11
• Ditillo, M. (2012). Capillary Leak and Fluid Resuscitation. In Intra-abdominal Hypertension: Core Critical Care Topics. New York: Cambridge Univiersity Press.
• Ditillo, M. (2012). Nutritional Management of Gastro-Enterocutaneous Fistulae. In Surgery of Complex Abdominal Wall Defects. New York: Spring Publishing.

Journals/Publications

• Akl, M. N., El-Qawaqzeh, K., Anand, T., Hosseinpour, H., Colosimo, C., Nelson, A., Alizai, Q., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis. Journal of Surgical Research. doi:10.1016/j.jss.2023.09.008
  More info

  There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy.We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed.Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value
• Akl, M., El-Qawaqzeh, K., Anand, T., Hosseinpour, H., Colosimo, C., Nelson, A., Alizai, Q., Ditillo, M., Magnotti, L., & Joseph, B. (2024). Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis. Journal of Surgical Research, 294. doi:10.1016/j.jss.2023.09.008
  More info

  Introduction: There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy. Methods: We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed. Results: Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value
• 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
  More info

  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
• 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
  More info

  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
  More info

  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
  More info

  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
  More info

  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
• Bhogadi, S., Stewart, C., Hosseinpour, H., Nelson, A., Ditillo, M., Matthews, M., Magnotti, L., & Joseph, B. (2024). Outcomes of Patients With Traumatic Brain Injury Transferred to Trauma Centers. JAMA Surgery. doi:10.1001/jamasurg.2024.3254
  More info

  IMPORTANCE Wide variations exist in traumatic brain injury (TBI) management strategies and transfer guidelines across the country. OBJECTIVE To assess the outcomes of patients with TBI transferred to the American College of Surgeons (ACS) level I (LI) or level II (LII) trauma centers (TCs) on a nationwide scale. DESIGN, SETTING, AND PARTICIPANTS In this secondary analysis of the ACS Trauma Quality Improvement Program database (2017 to 2020), adult patients with isolated TBI (nonhead abbreviated injury scale = 0) with intracranial hemorrhage (ICH) who were transferred to LI/LII TCs we re included. Data were analyzed from January 1, 2017, through December 31, 2020. MAIN OUTCOMES AND MEASURES Outcomes were rates of head computed tomography scans, neurosurgical interventions (cerebral monitors, craniotomy/craniectomy), hospital length of stay, and mortality. Descriptive statistics and hierarchical mixed-model regression analyses were performed. RESULTS Of 117 651 patients with TBI with ICH managed at LI/LII TCs 53 108; (45.1%; 95% CI, 44.8%-45.4%) transferred from other centers were identified. The mean (SD) age was 61 (22) years and 30 692 were male (58%). The median (IQR) Glasgow Coma Scale score on arrival was 15 (14-15); 5272 patients had a Glasgow Coma Scale score of 8 or less on arrival at the receiving trauma center (10%). A total of 30 973 patients underwent head CT scans (58%) and 2144 underwent repeat head CT scans at the receiving TC (4%). There were 2124 patients who received cerebral monitors (4%), 6862 underwent craniotomy/craniectomy (13%), and 7487 received mechanical ventilation (14%). The median (IQR) hospital length of stay was 2 (1-5) days and the mortality rate was 6.5%. There were 9005 patients (17%) who were discharged within 24 hours and 19 421 (37%) who were discharged within 48 hours of admission without undergoing any neurosurgical intervention. Wide variations between and within trauma centers in terms of outcomes were observed in mixed-model analysis. CONCLUSIONS In this study, nearly half of the patients with TBI managed at LI/LII TCs were transferred from lower-level hospitals. Over one-third of these transferred patients were discharged within 48 hours without any interventions. These findings indicate the need for systemwide guidelines to improve health care resource use and guide triage of patients with TBI.
• 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
  More info

  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.
• 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
  More info

  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., 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?. Journal of Surgical Research. doi:10.1016/j.jss.2023.09.015
  More info

  Introduction 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. Methods This is a retrospective analysis of 2017-2019 American College of Surgeons Trauma Quality Improvement Program. We included moderate to severely injured (Injury Severity Score >8) older adult (≥65 y) trauma patients. Patients were stratified into geriatric (65 y ≤ Age
• El-Qawaqzeh, K., Anand, T., Alizai, Q., Colosimo, C., Hosseinpour, H., Spencer, A., Ditillo, M., Magnotti, L., Stewart, C., & Joseph, B. (2024). Trauma in the Geriatric and the Super-Geriatric: Should They Be Treated the Same?. Journal of Surgical Research, 293. doi:10.1016/j.jss.2023.09.015
  More info

  Introduction: 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. Methods: This is a retrospective analysis of 2017-2019 American College of Surgeons Trauma Quality Improvement Program. We included moderate to severely injured (Injury Severity Score >8) older adult (≥65 y) trauma patients. Patients were stratified into geriatric (65 y ≤ Age
• 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
  More info

  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.
• 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
  More info

  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.
• Hosseinpour, H., Nelson, A., Bhogadi, S., Magnotti, L., Alizai, Q., Colosimo, C., Hage, K., Ditillo, M., Anand, T., & Joseph, B. (2024). Should We Keep or Transfer Our Severely Injured Geriatric Patients to Higher Levels of Care?. Journal of Surgical Research, 300. doi:10.1016/j.jss.2024.03.049
  More info

  Introduction: Interfacility transfer to higher levels of care is becoming increasingly common. This study aims to evaluate the association between transfer to higher levels of care and prolonged transfer times with outcomes of severely injured geriatric trauma patients compared to those who are managed definitively at lower-level trauma centers. Methods: Severely injured (Injury Severity Score >15) geriatric (≥60 y) trauma patients in the 2017-2018 American College of Surgeons Trauma Quality Improvement Program database managing at an American College of Surgeons/State Level III trauma center or transferring to a level I or II trauma center were included. Outcome measures were 24-h and in-hospital mortality and major complications. Results: Forty thousand seven hundred nineteen patients were identified. Mean age was 75 ± 8 y, 54% were male, 98% had a blunt mechanism of injury, and the median Injury Severity Score was 17 [16-21]. Median transfer time was 112 [79-154] min, and the most common transport mode was ground ambulance (82.3%). Transfer to higher levels of care within 90 min was associated with lower 24-h mortality (adjusted odds ratio [aOR]: 0.493, P < 0.001) and similar odds of in-hospital mortality as those managed at level III centers. However, every 30-min delay in transfer time beyond 90 min was progressively associated with increased odds of 24-h (aOR: 1.058, P < 0.001) and in-hospital (aOR: 1.114, P < 0.001) mortality and major complications (aOR: 1.127, P < 0.001). Conclusions: Every 30-min delay in interfacility transfer time beyond 90 min is associated with 6% and 11% higher risk-adjusted odds of 24-h and in-hospital mortality, respectively. Estimated interfacility transfer time should be considered while deciding about transferring severely injured geriatric trauma patients to a higher level of care.
• Hosseinpour, H., Stewart, C., Hejazi, O., Okosun, S., Khurshid, M., Nelson, A., Bhogadi, S., Ditillo, M., Magnotti, L., & Joseph, B. (2024). FINDING THE SWEET SPOT: THE ASSOCIATION BETWEEN WHOLE BLOOD TO RED BLOOD CELLS RATIO AND OUTCOMES OF HEMORRHAGING CIVILIAN TRAUMA PATIENTS. Shock, 62(3). doi:10.1097/SHK.0000000000002405
  More info

  Purpose: To evaluate the dose-dependent effect of whole blood (WB) on the outcomes of civilian trauma patients with hemorrhagic shock. Methods: We performed a 2-year (2020–2021) retrospective analysis of the ACS-TQIP dataset. Adult (≥18) trauma patients with a shock index (SI) >1 who received at least 5 units of PRBC and one unit of WB within the first 4 h of admission were included. Primary outcomes were 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications and hospital and intensive care unit length of stay. Results: A total of 830 trauma patients with a mean (SD) age of 38 (16) were identified. The median [IQR] 4-h WB and PRBC requirements were 2 [2–4] U and 10 [7–15] U, respectively, with a median WB:RBC ratio of 0.2 [0.1–0.3]. Every 0.1 increase in WB:RBC ratio was associated with decreased odds of 24-h mortality (aOR: 0.916, P = 0.035) and in-hospital mortality (aOR: 0.878, P < 0.001). Youden’s index identified 0.25 (1 U of WB for every 4 U of PRBC) as the optimal WB:PRBC ratio to reduce 24-h mortality. High ratio (≥0.25) group had lower adjusted odds of 24-h mortality (aOR: 0.678, P = 0.021) and in-hospital mortality (aOR: 0.618, P < 0.001) compared to the low ratio group. Conclusions: A higher WB:PRBC ratio was associated with improved early and late mortality in trauma patients with hemorrhagic shock. Given the availability of WB in trauma centers across the United States, at least one unit of WB for every 4 units of packed red blood cells may be administered to improve the survival of hemorrhaging civilian trauma patients.
• 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
  More info

  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
  More info

  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 [
• 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?. Journal of Surgical Research. doi:10.1016/j.jss.2023.08.049
  More info

  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.We performed a retrospective analysis of American College of Surgeons Trauma Quality Improvement Program (2018). We included geriatric (≥65 y) trauma patients who sustained a concomitant burn injury with ≥10% Total Body Surface Area affected. Patients with body region-specific AIS ≥4 were excluded. Patients were stratified into Frail and Nonfrail, using 5-factor modified Frailty Index. Primary outcomes measured were mortality. Secondary outcomes measured were complications, and hospital and intensive care unit (ICU) length of stay (LOS). Multivariable logistic regression was performed to identify independent predictors of mortality.A total of 574 patients were identified, of which 172(30%) were Frail. Mean age was 74 ± 7 y and median [interquartile range] ISS was 3[1-10]. Overall, the rate of mortality was 23% and median hospital LOS was 14[3-31]. After controlling for potential confounding factors, frailty was not identified as an independent predictor of mortality (adjusted odds ratio:1.059, P = 0.93) and complications (adjusted odds ratio:1.10, P = 0.73). However, frail patients had longer hospital (β: 5.01, P = 0.002) and ICU LOS (β: 2.12, P < 0.001).Among geriatric trauma patients with concomitant burn injuries, frailty is associated with longer hospital and ICU LOS, and higher rates of thrombotic complications, but not higher mortality or overall complications. Future research should investigate the impact of early assessment of frailty as well as tailored interventions on outcomes in this population.
• Litmanovich, B., Alizai, Q., Stewart, C., Hosseinpour, H., Nelson, A., Bhogadi, S., Colosimo, C., Spencer, A., Ditillo, M., & Joseph, B. (2024). Outcomes of Geriatric Burn Patients Presenting to the Trauma Service: How Does Frailty Factor in?. Journal of Surgical Research, 293. doi:10.1016/j.jss.2023.08.049
  More info

  Introduction: 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. Methods: We performed a retrospective analysis of American College of Surgeons Trauma Quality Improvement Program (2018). We included geriatric (≥65 y) trauma patients who sustained a concomitant burn injury with ≥10% Total Body Surface Area affected. Patients with body region-specific AIS ≥4 were excluded. Patients were stratified into Frail and Nonfrail, using 5-factor modified Frailty Index. Primary outcomes measured were mortality. Secondary outcomes measured were complications, and hospital and intensive care unit (ICU) length of stay (LOS). Multivariable logistic regression was performed to identify independent predictors of mortality. Results: A total of 574 patients were identified, of which 172(30%) were Frail. Mean age was 74 ± 7 y and median [interquartile range] ISS was 3[1-10]. Overall, the rate of mortality was 23% and median hospital LOS was 14[3-31]. After controlling for potential confounding factors, frailty was not identified as an independent predictor of mortality (adjusted odds ratio:1.059, P = 0.93) and complications (adjusted odds ratio:1.10, P = 0.73). However, frail patients had longer hospital (β: 5.01, P = 0.002) and ICU LOS (β: 2.12, P < 0.001). Conclusions: Among geriatric trauma patients with concomitant burn injuries, frailty is associated with longer hospital and ICU LOS, and higher rates of thrombotic complications, but not higher mortality or overall complications. Future research should investigate the impact of early assessment of frailty as well as tailored interventions on outcomes in this population.
• Akl, M. N., El-Qawaqzeh, K., Anand, T., Hosseinpour, H., Colosimo, C., Nelson, A., Alizai, Q., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis. The Journal of surgical research, 294, 128-136.
  More info

  There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy.
• 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.
  More info

  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. doi:10.1016/j.injury.2023.111184
  More info

  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 Bulger EM Arneson MA Mock CN Jurkovich GJ. Rib fractures in the elderly. 50 Landmark Papers every Trauma Surgeon Should Know. CRC Press, 2019: 189-192 Google Scholar , 4 Ziegler DW Agarwal NN. The morbidity and mortality of rib fractures. J Trauma Acute Care Surg. 1994; 37: 975-979 Crossref Scopus (474) Google Scholar , 5 Holcomb JB McMullin NR Kozar RA Lygas MH Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg. 2003; 196: 549-555 Crossref PubMed Scopus (268) Google Scholar , 6 Barry R Thompson E. Outcomes after rib fractures in geriatric blunt trauma patients. Am J Surg. 2018; 215: 1020-1023 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar , 7 Davies RG Myles PS Graham J. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2006; 96: 418-426 Abstract Full Text Full Text PDF PubMed Scopus (551) Google Scholar , 8 Duch P Møller M. Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials. Acta Anaesthesiol Scand. 2015; 59: 698-709 Crossref PubMed Scopus (36) Google Scholar , 9 Zaw AA Murry J Hoang D Chen K Louy C Bloom MB et al. Epidural analgesia after rib fractures. Am Surg. 2015; 81: 950-954 Crossref PubMed Google Scholar , 10 Jensen CD Stark JT Jacobson LL Powers JM Joseph MF Kinsella-Shaw JM et al. Improved outcomes associated with the liberal use of thoracic epidural analgesia in patients with rib fractures. Pain Med. 2017; 18: 1787-1794 PubMed Google Scholar , 11 Kelley KM Burgess J Weireter L Novosel TJ Parks K Aseuga M et al. Early use of a chest trauma protocol in elderly patients with rib fractures improves pulmonary outcomes. Am Surg. 2019; 85: 288-291 Crossref PubMed Google Scholar , 12 Ekpe EE Eyo C. Effect of analgesia on the changes in respiratory parameters in blunt chest injury with multiple rib fractures. Ann. Afr. Med. 2017; 16: 120 Crossref PubMed Scopus (5) Google Scholar , 13 He Z Zhang D Xiao H Zhu Q Xuan Y Su K et al. The ideal methods for the management of rib fractures. J Thoracic Dis. 2019; 11: S1078 Crossref PubMed Scopus (21) Google Scholar , 14 Bulger EM Arneson MA Mock CN Jurkovich GJ. Rib fractures in the elderly. J Trauma Acute Care Surg. 2000; 48: 1040-1047 Crossref Scopus (541) Google Scholar , 15 Kim M Moore JE. Chest trauma: current recommendations for rib fractures, pneumothorax, and other injuries. Curr Anesthesiol Rep. 2020; 10: 61-68 Crossref PubMed Scopus (27) Google Scholar ], median chest AIS was 3 [ 2 Contol CoD. Public Health and Aging: Trends in Aging — United States and Worldwide. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5206a2.htm Google Scholar , 3 Bulger EM Arneson MA Mock CN Jurkovich GJ. Rib fractures in the elderly. 50 Landmark Papers every Trauma Surgeon Should Know. CRC Press, 2019: 189-192 Google Scholar , 4 Ziegler DW Agarwal NN. The morbidity and mortality of rib fractures. J Trauma Acute Care Surg. 1994; 37: 975-979 Crossref Scopus (474) Google Scholar ], 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 Ziegler DW Agarwal NN. The morbidity and mortality of rib fractures. J Trauma Acute Care Surg. 1994; 37: 975-979 Crossref Scopus (474) Google Scholar , 5 Holcomb JB McMullin NR Kozar RA Lygas MH Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg. 2003; 196: 549-555 Crossref PubMed Scopus (268) Google Scholar , 6 Barry R Thompson E. Outcomes after rib fractures in geriatric blunt trauma patients. Am J Surg. 2018; 215: 1020-1023 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar , 7 Davies RG Myles PS Graham J. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2006; 96: 418-426 Abstract Full Text Full Text PDF PubMed Scopus (551) Google Scholar , 8 Duch P Møller M. Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials. Acta Anaesthesiol Scand. 2015; 59: 698-709 Crossref PubMed Scopus (36) Google Scholar , 9 Zaw AA Murry J Hoang D Chen K Louy C Bloom MB et al. Epidural analgesia after rib fractures. Am Surg. 2015; 81: 950-954 Crossref PubMed Google Scholar , 10 Jensen CD Stark JT Jacobson LL Powers JM Joseph MF Kinsella-Shaw JM et al. Improved outcomes associated with the liberal use of thoracic epidural analgesia in patients with rib fractures. Pain Med. 2017; 18: 1787-1794 PubMed Google Scholar ] 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
• 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.
  More info

  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.
  More info

  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.
• Anand, T., Bhogadi, S. K., Cooper, Z., Ditillo, M., El-Qawaqzeh, K., Gries, L., Hosseinpour, H., Joseph, B., Magnotti, L. J., & Stewart, C. (2023).

  Dealing with the elder abuse epidemic: Disparities in interventions against elder abuse in trauma centers

  . Journal of the American Geriatrics Society. doi:10.1111/jgs.18286
  More info

  Background Elder abuse is a major cause of injury, morbidity, and death. We aimed to identify the factors associated with interventions against suspected physical abuse in older adults. Methods Analysis of the 2017–2018 ACS TQIP. All trauma patients ≥60 years with an abuse report for suspected physical abuse were included. Patients with missing information on abuse interventions were excluded. Outcomes were rates of abuse investigation initiation following an abuse report and change of caregiver at discharge among survivors with an abuse investigation initiated. Multivariable regression analyses were performed. Results Of 727,975 patients, 1405 (0.2%) had an abuse report. Patients with an abuse report were younger (mean, 72 vs 75, p < 0.001), and more likely to be females (57% vs 53%, p = 0.007), Hispanic (11% vs 6%, p < 0.001), Black (15% vs 7%, p < 0.001), suffer from dementia (18% vs 11%, p < 0.001), functional disability (19% vs 15%, p < 0.001), have a positive admission drug screen (9% vs 5%, p < 0.001) and had a higher ISS (median [IQR], 9 [4–16] vs 6 [3–10], p < 0.001). Perpetrators were members of the immediate/step/extended family in 91% of cases. Among patients with an abuse report, 1060 (75%) had abuse investigations initiated. Of these, 227 (23%) resulted in a change of caregiver at discharge. On multivariate analysis for abuse investigation initiation, male gender, private insurance, and management at non-level I trauma centers were associated with lower adjusted odds (p < 0.05), while Hispanic ethnicity, positive admission drug screen, and penetrating injury were associated with higher adjusted odds (p < 0.05). On multivariate analysis for change of caregiver, male gender, and private insurance were associated with lower adjusted odds (p < 0.05), while functional disability and dementia were associated with higher adjusted odds (p < 0.05). Conclusions Significant gender, ethnic, and socioeconomic disparities exist in the management of physical abuse of older adults. Further studies are warranted to expand on and address the contributing factors underlying these disparities. Level of Evidence III. Study Type Therapeutic/Care Management.
• Anand, T., El-Qawaqzeh, K., Nelson, A., Hosseinpour, H., Ditillo, M., Gries, L., Castanon, L., & Joseph, B. (2023). Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures. JAMA surgery, 158(1), 63-71.
  More info

  Management of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture.
• 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.
  More info

  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.
  More info

  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., Colosimo, C., Hosseinpour, H., Nelson, A., Rose, M., Calvillo, A. R., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). The Undisclosed Disclosures: The Dollar-Outcome Relationship In Resuscitative Endovascular Balloon Occlusion of the Aorta. The Journal of Trauma and Acute Care Surgery. doi:10.1097/ta.0000000000004080
  More info

  Despite its rapid evolution, resuscitative endovascular balloon occlusion of the aorta (REBOA) remains a controversial intervention that continues to generate active research. Proper conflict of interest (COI) disclosure helps to ensure that research is conducted objectively, without bias. We aimed to identify the accuracy of COI disclosures in REBOA research.Literature search was performed using the keyword "REBOA" on PubMed. Studies on REBOA with at least one American author published between 2017 and 2022 were identified. The Centers for Medicare and Medicaid Services Open Payments database was used to extract information regarding payments to the authors from the industry. This was compared with the COI section reported in the manuscripts. Conflict of interest disclosure was defined as inaccurate if the authors failed to disclose any amount of money received from the industry. Descriptive statistics were performed.We reviewed a total of 524 articles, of which 288 articles met the inclusion criteria. At least one author received payments in 57% (165) of the articles. Overall, 59 authors had a history of payment from the industry. Conflict of interest disclosure was inaccurate in 88% (145) of the articles where the authors received payment.Conflict of interest reports are highly inaccurate in REBOA studies. There needs to be standardization of reporting of conflicts of interest to avoid potential bias.Prognostic and Epidemiological; Level IV.
• 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.
  More info

  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.
• 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.
  More info

  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 
• Collins, W. J., El-Qawaqzeh, K., Ditillo, M., Hosseinpour, H., Nelson, A., Bhogadi, S. K., Castañón, L., Gries, L., Anand, T., & Joseph, B. (2023). Minimally Invasive Surgery for Genitourinary Trauma: A Nationwide Outcomes-Based Analysis. Journal of Surgical Research. doi:10.1016/j.jss.2022.09.015
  More info

  Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes.We performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality.Of the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) CONCLUSIONS: In our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries.
• Collins, W., El-Qawaqzeh, K., Ditillo, M., Hosseinpour, H., Nelson, A., Bhogadi, S., Castanon, L., Gries, L., Anand, T., & Joseph, B. (2023). Minimally Invasive Surgery for Genitourinary Trauma: A Nationwide Outcomes-Based Analysis. Journal of Surgical Research, 282. doi:10.1016/j.jss.2022.09.015
  More info

  Introduction: Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes. Methods: We performed a 2017 review of American College of Surgeons Trauma Quality Improvement Program and identified trauma patients with bladder and ureteral injury who underwent open surgical repair or laparoscopy. A 1:1 propensity score matching was performed adjusting for demographics, emergency department vitals (systolic blood pressure, heart rate, Glasgow Coma Scale), mechanism of injury, Injury Severity Score, each body region Abbreviated Injury Scale score, and transfusion units. Outcomes were rates of in-hospital major complications and mortality. Results: Of the 1,004,440 trauma patients, 384 patients (open: 192 and laparoscopy: 192) were matched and included. The mean age was 36 ± 15 y, Injury Severity Score was 27 [27-48], 77% were males, and 56% of patients had a blunt mechanism of injury, and 44% had penetrating injuries. Overall mortality was 7.3%. On univariate analysis, mortality was lower in the open group as compared to the laparoscopy group (10.4% versus 4.2%, P = 0.019) and survivor-only hospital length of stay was longer in the open group (8 [8-9] versus 7 [5-11], P = 0.008). There was no difference in overall major complications (23% versus 21%, P = 0.621). On multivariate analysis, open surgical repair was independently associated with lower odds of mortality (adjusted odds ratio: 0.405, 95% confidence interval: [0.17-0.95], P-value = 0.038) Conclusions: In our analysis open surgical repair of bladder and ureteral injuries was associated with lower mortality with other outcomes being similar when compared to laparoscopy. Laparoscopic surgical repair may not have an advantage over the open surgical repair for bladder and ureteral injuries. Further prospective studies are needed to delineate the ideal surgical approach for these injuries.
• El-Qawaqzeh, K., Anand, T., Alizai, Q., Colosimo, C., Hosseinpour, H., Spencer, A., Ditillo, M., Magnotti, L. J., Stewart, C., & Joseph, B. (2023). Trauma in the Geriatric and the Super-Geriatric: Should They Be Treated the Same?. The Journal of surgical research, 293, 316-326.
  More info

  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., Anand, T., Richards, J. W., Hosseinpour, H., Nelson, A., Akl, M. N., Obaid, O., Ditillo, M., Friese, R. S., & Joseph, B. (2023). Predictors of Mortality in Blunt Cardiac Injury: A Nationwide Analysis. Journal of Surgical Research. doi:10.1016/j.jss.2022.07.047
  More info

  Blunt thoracic injury (BTI) is one of the most common causes of trauma admission in the United States and is uncommonly associated with cardiac injuries. Blunt cardiac injury (BCI) after blunt thoracic trauma is infrequent but carries a substantial risk of morbidity and sudden mortality. Our study aims to identify predictors of concomitant cardiac contusion among BTI patients and the predictors of mortality among patients presenting with BCI on a national level.We performed a 1-y (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adults (aged ≥ 18 y) with the diagnosis of BTI. We excluded patients who were transferred, had a penetrating mechanism of injury, and who were dead on arrival. Our primary outcomes were the independent predictors of concomitant cardiac contusions among BTI patients and the predictors of mortality among BCI patients. Our secondary outcome measures were in-hospital complications, differences in injury patterns, and injury severity between the survivors and nonsurvivors of BCI.A total of 125,696 patients with BTI were identified, of which 2368 patients had BCI. Mean age was 52 ± 20 y, 67% were male, and median injury severity score was 14 [9-21]. The most common type of cardiac injury was cardiac contusion (43%). Age ≥ 65 y, higher 4-h packed red blood cell requirements, motor vehicle collision mechanism of injury, and concomitant thoracic injuries (hemothorax, flail chest, lung contusion, sternal fracture, diaphragmatic injury, and thoracic aortic injuries) were independently associated with concomitant cardiac contusion among BTI patients (P value < 0.05). Age ≥ 65 y, thoracic aortic injury, diaphragmatic injury, hemothorax, and a history of congestive heart failure were independently associated with mortality in BCI patients (P value < 0.05).Predictors of concomitant cardiac contusion among BTI patients and mortality among BCI patients were identified. Guidelines on the management of BCI should incorporate these predictors for timely identification of high-risk patients.
• El-Qawaqzeh, K., Anand, T., Richards, J., Hosseinpour, H., Nelson, A., Akl, M., Obaid, O., Ditillo, M., Friese, R., & Joseph, B. (2023). Predictors of Mortality in Blunt Cardiac Injury: A Nationwide Analysis. Journal of Surgical Research, 281. doi:10.1016/j.jss.2022.07.047
  More info

  Introduction: Blunt thoracic injury (BTI) is one of the most common causes of trauma admission in the United States and is uncommonly associated with cardiac injuries. Blunt cardiac injury (BCI) after blunt thoracic trauma is infrequent but carries a substantial risk of morbidity and sudden mortality. Our study aims to identify predictors of concomitant cardiac contusion among BTI patients and the predictors of mortality among patients presenting with BCI on a national level. Materials and Methods: We performed a 1-y (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adults (aged ≥ 18 y) with the diagnosis of BTI. We excluded patients who were transferred, had a penetrating mechanism of injury, and who were dead on arrival. Our primary outcomes were the independent predictors of concomitant cardiac contusions among BTI patients and the predictors of mortality among BCI patients. Our secondary outcome measures were in-hospital complications, differences in injury patterns, and injury severity between the survivors and nonsurvivors of BCI. Results: A total of 125,696 patients with BTI were identified, of which 2368 patients had BCI. Mean age was 52 ± 20 y, 67% were male, and median injury severity score was 14 [9-21]. The most common type of cardiac injury was cardiac contusion (43%). Age ≥ 65 y, higher 4-h packed red blood cell requirements, motor vehicle collision mechanism of injury, and concomitant thoracic injuries (hemothorax, flail chest, lung contusion, sternal fracture, diaphragmatic injury, and thoracic aortic injuries) were independently associated with concomitant cardiac contusion among BTI patients (P value < 0.05). Age ≥ 65 y, thoracic aortic injury, diaphragmatic injury, hemothorax, and a history of congestive heart failure were independently associated with mortality in BCI patients (P value < 0.05). Conclusions: Predictors of concomitant cardiac contusion among BTI patients and mortality among BCI patients were identified. Guidelines on the management of BCI should incorporate these predictors for timely identification of high-risk patients.
• El-Qawaqzeh, K., Colosimo, C., Bhogadi, S. K., Magnotti, L. J., Hosseinpour, H., Castanon, L., Nelson, A., Ditillo, M., Anand, T., & Joseph, B. (2023). Unequal Treatment? Confronting Racial, Ethnic, and Socioeconomic Disparity in Management of Survivors of Violent Suicide Attempt. Journal of the American College of Surgeons, 237(1), 68-78.
  More info

  Psychiatric inpatient hospitalization is nearly always indicated for patients with recent suicidal behavior. We aimed to assess the factors associated with receiving mental health services during hospitalization or on discharge among survivors of suicide attempts in trauma centers.
• El-Qawaqzeh, K., Hosseinpour, H., Gries, L., Magnotti, L. J., Bhogadi, S. K., Anand, T., Ditillo, M., Stewart, C., Cooper, Z., & Joseph, B. (2023). Dealing with the elder abuse epidemic: Disparities in interventions against elder abuse in trauma centers. Journal of the American Geriatrics Society, 71(6), 1735-1748.
  More info

  Elder abuse is a major cause of injury, morbidity, and death. We aimed to identify the factors associated with interventions against suspected physical abuse in older adults.
• 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.
  More info

  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.
• Hanna, K., Chehab, M., Bible, L., Asmar, S., Ditillo, M., Castanon, L., Tang, A., & Joseph, B. (2023). Failure to Rescue in Emergency General Surgery: Impact of Fragmentation of Care. Annals of Surgery, 277(1). doi:10.1097/SLA.0000000000004628
  More info

  Objective: Compare EGS patient outcomes after index and nonindex hospital readmissions, and explore predictive factors for nonindex readmission. Background: Readmission to a different hospital leads to fragmentation of care. The impact of nonindex readmission on patient outcomes after EGS is not well established. Methods: The Nationwide Readmissions Database (2017) was queried for adult patients readmitted after an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index versus nonindex hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital length of stay, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. Results: A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) versus nonindex hospital (17,655; 22.3%). After 1:1 propensity matching, patients with nonindex readmission had higher rates of FTR (5.6% vs 4.3%; P < 0.001), mortality (2.7% vs 2.1%; P < 0.001), and overall hospital costs [in $1000; 37 (27-64) vs 28 (21-48); P < 0.001]. Nonindex readmission was independently associated with higher odds of FTR [adjusted odds ratio 1.18 (1.03-1.36); P < 0.001]. Predictors of nonindex readmission included top quartile for zip code median household income [1.35 (1.08-1.69); P < 0.001], fringe county residence [1.08 (1.01-1.16); P = 0.049], discharge to a skilled nursing facility [1.28 (1.20-1.36); P < 0.001], and leaving against medical advice [2.32 (1.81-2.98); P < 0.001]. Conclusion: One in 5 readmissions after EGS occur at a different hospital. Nonindex readmission carries a heightened risk of FTR. Level of Evidence: Level III Prognostic. Study Type: Prognostic.
• 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.
  More info

  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.
  More info

  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.
  More info

  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.
  More info

  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.
  More info

  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. (2023). Outcomes of Geriatric Burn Patients Presenting to the Trauma Service: How Does Frailty Factor in?. The Journal of surgical research, 293, 327-334.
  More info

  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.
• Lundy, M. E., Zhang, B., & Ditillo, M. (2023). Management of the Geriatric Trauma Patient. The Surgical Clinics of North America Volume 104, Issue 2. doi:10.1016/j.suc.2023.09.010
  More info

  With a rapidly aging worldwide population, the care of geriatric trauma patients will be at the forefront of every career in Trauma and Acute Care Surgery. The unique intersection of advanced age, comorbidities, frailty, and physiologic changes presents a challenge in the care of elderly injured patients. It is well established that increasing age is associated with higher mortality and worse outcomes after injury, but it is also clear that there is room for improvement in the management of this special patient population.
• Akl, M., Anand, T., Reina, R., El-Qawaqzeh, K., Ditillo, M., Hosseinpour, H., Nelson, A., Obaid, O., Friese, R., & Joseph, B. (2022). Balanced hemostatic resuscitation for bleeding pediatric trauma patients: A nationwide quantitative analysis of outcomes. Journal of pediatric surgery.
  More info

  The administration of balanced component therapy has been associated with improvements in outcomes in adult trauma. There is little to no specific data to guide transfusion ratios in children. The aim of our study is to compare outcomes among different transfusion strategies in pediatric trauma patients.
• Anand, T., Nelson, A., Obaid, O., Ditillo, M., El-Qawaqzeh, K. W., Stewart, C., Limon, R. F., Hosseinpour, H., Nguyen, L., Joseph, B., Anand, T., Nelson, A., Obaid, O., Ditillo, M., El-Qawaqzeh, K. W., Stewart, C., Limon, R. F., Hosseinpour, H., Nguyen, L., & Joseph, B. (2022). Futility of Resuscitation among Geriatric Trauma Patients: Do We Need to Define When to Withdraw Care?. Journal of the American College of Surgeons, 235(5), S92-S93. doi:10.1097/01.xcs.0000896516.60590.12
  More info

  Introduction: Survival15) geriatric trauma patients(≥65yrs). FR was. Patients were stratified into decades of age and resuscitative endpoints and intervention employed were identified. Outcome was FR (any intervention/endpoint that was associated with >90% mortality). Results: 46,339 patients were identified (65-75yrs: 42%; 75-85yrs: 40%; ≥85yrs: 18%). Mortality was 18%, ISS was 21[17-26], 57% male, and 85% blunt-injury. ED-thoracotomy among those >65yrs, and prehospital cardiac-arrest and REBOA among those >85yrs were associated with FR. Transfusion of >40U PRBC or FFP within 24hrs was associated with FR. 4-hour PRBC volumes associated with FR were: 65-75yrs:>30U; 75-85yrs:>27U; >85yrs:>21U. Increasing age was associated with increasing mortality among those who received emergency laparotomy or vasopressors, but did not reach FR. Lowest in-hospital SBP < 50mmHg was associated with FR among those>85yrs. Conclusion: ED-thoracotomy and transfusions >40U of product are futile in anyone over 65. REBOA is futile in anyone over 85. Resuscitation is futile in all super-elderly with prehospital cardiac arrest or an episode of profound hypotension. Further studies redefining FR among the geriatric trauma patient population to include lower mortality rates may be warranted.
• Asmar, S., Nelson, A., Anand, T., Hammad, A. M., Obaid, O., Ditillo, M., Saljuqi, A. T., Tang, A., & Joseph, B. (2022). Marijuana and thromboembolic events in geriatric trauma patients: The cannabinoids clots correlation!. The American Journal of Surgery. doi:10.1016/j.amjsurg.2021.07.036
  More info

  Tetrahydrocannabinol (THC) can alter the coagulation cascade resulting in hypercoagulability. The aim of our study is to evaluate the impact of THC use on thromboembolic complications (TEC) in geriatric trauma patients (GTP).This is a 2017 analysis of the TQIP database including all GTP (age ≥65 years). Patients were stratified based on THC use. Propensity score matching (1:2 ratio) was performed.A total of 2,835 patients were matched (THC+: 945 and THC-: 1,890). Mean age was 70 ± 6 years, 94% sustained blunt injuries, and median ISS was 22[12-27]. Sixty-two percent of patients received thromboprophylaxis, with median time to initiation of 27 h from admission. Overall, the rate of TEC was 2.1% and mortality was 6.0%. THC + patients had significantly higher rates of TEC compared to THC- patients (3.0% vs. 1.7%; p = 0.01). Rates of DVT (2.2% vs 0.6%, p < 0.01) and PE (1.4% vs 0.4%, p < 0.01) were higher in the THC + group.THC exposure increases the risk of TEC in GTP. Incorporation of THC use into risk assessment protocols merits serious consideration in GTP.
• Collins, W. J., El-Qawaqzeh, K., Ditillo, M., Hosseinpour, H., Nelson, A., Bhogadi, S. K., Castanon, L., Gries, L., Anand, T., & Joseph, B. (2022). Minimally Invasive Surgery for Genitourinary Trauma: A Nationwide Outcomes-Based Analysis. The Journal of surgical research, 282, 129-136.
  More info

  Bladder and ureteral injuries are uncommon in trauma patients but are associated with increased morbidity and mortality. Patients presenting with such injuries may undergo either open surgical repair or laparoscopic repair. We aimed to compare outcomes of open surgical approach and laparoscopy in trauma patients with isolated bladder and ureteral injury. We hypothesized that laparoscopy is associated with improved outcomes.
• Douglas, M., Obaid, O., Castanon, L., Reina, R., Ditillo, M., Nelson, A., Bible, L., Anand, T., Gries, L., & Joseph, B. (2022). After 9,000 laparotomies for blunt trauma, resuscitation is becoming more balanced and time to intervention shorter: Evidence in action. The journal of trauma and acute care surgery, 93(3), 307-315.
  More info

  Several advancements in hemorrhage control have been advocated for in the past decade, including balanced transfusions and earlier times to intervention. The aim of this study was to examine the effect of these advancements on outcomes of blunt trauma patients undergoing emergency laparotomy.
• El-Qawaqzeh, K., Anand, T., Hosseinpour, H., Ditillo, M., Obaid, O., Nelson, A., Stewart, C., Nguyen, L., Limon, R. F., & Joseph, B. (2022). Nationwide Analysis of Outcomes after Resuscitative Endovascular Balloon Occlusion of the Aorta: Is There a Need for Age-Specific Considerations?. Journal of the American College of Surgeons, 235(5), S288-S289. doi:10.1097/01.xcs.0000895276.04948.e7
  More info

  INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing adjunctive hemorrhage control intervention. However, there is conflicting evidence on any survival benefits associated with REBOA. We aimed to assess the outcomes of adjunctive REBOA among different age groups. METHODS: We analyzed the 2017 to 2018 American College of Surgeons TQIP including adults (18 years or older) who received early transfusions and emergency hemorrhage control surgery (thoracotomy/laparotomy within 24 hours). After stratification into REBOA and no-REBOA, propensity score matching was performed. Patients were stratified into 4 age categories. Outcomes were in 24 hours, in-hospital mortality, major complications, and survivor hospital length of stay. RESULTS: We identified 19,984 patients, among whom 2,388 patients (REBOA: 796; no-REBOA: 1,592) were matched. The mean age was 42 ± 18 years, the mean lowest systolic blood pressure was 67 ± 35 mmHg, and the median Injury Severity Score was 29 [19 to 38]. The median time to hemorrhage control surgery was 48 [29 to 86] minutes. Overall, in-hospital mortality was 51%, the major complication rate was 34%, and the median length of stay among survivors was 19 [11 to 31] days. Univariate analysis is provided in figure. On multivariate regression, geriatric patients (65 years and older) in the REBOA group had significantly higher adjusted odds of both 24-hour mortality (adjusted odds ratio 2.05, p = 0.01) and in-hospital mortality (adjusted odds ratio 2.42, p = 0.01; Table). REBOA was independently associated with higher odds of major complications (adjusted odds ratio 1.25, p = 0.01) and longer hospital length of stay (β +3.37, p < 0.001) compared with no-REBOA.CONCLUSION: Adjunctive REBOA did not confer any survival benefit in patients undergoing emergency hemorrhage control surgery among all age groups. In fact, REBOA was independently associated with higher mortality in geriatric patients (65 years and older). There is a need for a concerted effort to clearly delineate which subset of patients will benefit from this resuscitation strategy.
• El-Qawaqzeh, K., Anand, T., Richards, J., Hosseinpour, H., Nelson, A., Akl, M. N., Obaid, O., Ditillo, M., Friese, R., & Joseph, B. (2022). Predictors of Mortality in Blunt Cardiac Injury: A Nationwide Analysis. The Journal of surgical research, 281, 22-32.
  More info

  Blunt thoracic injury (BTI) is one of the most common causes of trauma admission in the United States and is uncommonly associated with cardiac injuries. Blunt cardiac injury (BCI) after blunt thoracic trauma is infrequent but carries a substantial risk of morbidity and sudden mortality. Our study aims to identify predictors of concomitant cardiac contusion among BTI patients and the predictors of mortality among patients presenting with BCI on a national level.
• El-Qawaqzeh, K., Reina Limon, R. F., Hosseinpour, H., Ditillo, M. F., Obaid, O., Anand, T., Stewart, C., Nelson, A. C., Nguyen, L., & Joseph, B. (2022). Geriatric Trauma, Frailty, and American College of Surgeons Trauma Center Verification Level: Are There Any Correlations with Outcomes?. Journal of the American College of Surgeons, 235(5), S281-S281. doi:10.1097/01.xcs.0000895216.99457.23
  More info

  INTRODUCTION: Frailty is prevalent among the elderly and confers increased risk for adverse outcomes. We aimed to assess the effect of American College of Surgeons (ACS) trauma center verification level on outcomes among frail and nonfrail geriatric trauma patients. METHODS: We analyzed the 2017 to 2019 ACS-TQIP including geriatric (65 years or older) trauma patients who presented to ACS Level I, II, or III trauma centers. Patients who were transferred or had missing data on verification level and hospital discharge disposition were excluded. Modified frailty index was calculated. After stratification into frail and nonfrail, matching was performed. Outcomes were adverse discharge (rehabilitation/SNF) and mortality. RESULTS: We identified 286,054 patients, and 110,680 patients were matched (frail: 55,340; nonfrail: 55,340). Of these, 2.8% died, and 55% had adverse discharge. Geriatric patients had lower rates of adverse discharge in Level I and II centers compared with Level III centers (52.6%, 55.8%, 60.9%, p < 0.001) regardless of frailty and injury severity, and higher rates of mortality in Level I and II centers compared with Level III trauma centers (4.9%, 3.7%, 2.8%, p < 0.001) among the moderate-to-severely injured only. Frail patients were more likely to die and be discharged to rehabilitation/SNF (Table).ACS, American College of Surgeons; ISS, Injury Severity Score.CONCLUSION: Mortality is low regardless of injury severity for geriatric trauma patients managed at ACS trauma centers. More than half of geriatric trauma patients are discharged to rehabilitation/SNF. Higher-level centers have higher mortality but lower rates of adverse discharge, regardless of frailty status and injury severity, and Level III centers may be underperforming with regards to resource allocation. Higher-level centers may be prioritizing quality of life over survival. Further studies are required to explore the relationship between frailty, verification level, end-of-life decision making, and transfer practices.
• Hosseinpour, H., Ditillo, M., Limon, R. F., Anand, T., El-Qawaqzeh, K. W., Stewart, C., Obaid, O., Nelson, A., Nguyen, L., & Joseph, B. (2022). Emergency Department Shock Index Outperforms Prehospital and Delta Shock Indices at Predicting Outcomes of Trauma Patients: An Analysis of the Trauma Quality Improvement Program. Journal of the American College of Surgeons, 235(5), S279-S279. doi:10.1097/01.xcs.0000895200.15508.87
  More info

  INTRODUCTION: Multiple shock indices, including prehospital, emergency department (ED), and Delta (ED shock index [SI] minus prehospital SI), have been developed to predict outcomes. We aimed to compare the predictive abilities of prehospital, ED, and Delta SIs for outcomes of polytrauma patients. METHODS: We analyzed the 2017 to 2018 ACS-TQIP including adult (18 years and older) trauma patients, and excluded patients who were transferred, and those with severe traumatic brain injury (head AIS greater than 3). Prehospital and ED SIs were categorized into 3 groups: SI 0.7 or less, SI less than 0.7 but 0.9 or greater, and SI greater than 0.9, and into 2 groups based on Delta SI less than 0.1 and 0.1 or greater. Outcomes were 24-hour and in-hospital mortality, 24-hour PRBC transfusions, ICU, and hospital length of stay. Predictive performances of SIs were evaluated by AUC-ROC. Paired-sample design was performed to compare AUC (95% CI among SIs for outcomes. RESULTS: A total of 750,407 adult trauma patients were identified. The mean age was 53 ± 21 years, 59% were male, mean prehospital and ED pulse rates were 90 ± 21 and 87 ± 21 bpm, respectively. Overall, 24-hour and in-hospital mortality were 1.2% and 2.5%, respectively. On multivariate analysis, all 3 SIs were independently associated with higher rates of 24-hour mortality, in-hospital mortality, blood product transfusion, and ICU and hospital length of stay (p < 0.001). ED SI was superior to prehospital SI, Delta SI, SBP, and HR alone (p < 0.001) for all outcome measures except for in-hospital length of stay (p > 0.05; Figure).Figure.: ED, emergency department; ISS, Injury Severity Score; LOS, length of stay; SI, shock index.CONCLUSION: All SIs outperformed SBP and HR alone at predicting worse outcomes of trauma patients, but ED SI outperformed both prehospital and Delta SIs across all injury severities. Trauma triage guidelines should prioritize ED SI to identify patients who may benefit from earlier trauma activations.
• Hosseinpour, H., Stewart, C., Obaid, O., Ditillo, M., El-Qawaqzeh, K. W., Nelson, A., Limon, R. F., Anand, T., Nguyen, L., & Joseph, B. (2022). Increased Mortality for Transferred Trauma Patients: Should Transfer Time Become the Next Quality of Care Indicator?. Journal of the American College of Surgeons, 235(5), S285-S286. doi:10.1097/01.xcs.0000895252.85714.6e
  More info

  INTRODUCTION: Prehospital transport mode and time is correlated with trauma patient outcomes. The aim of our study is to evaluate the effect of transport time on nationwide outcomes for severely injured adults who were transferred to a higher level of care. METHODS: We analyzed 2017 to 2018 American College of Surgeons TQIP. Severely injured (Injury Severity Score greater than 15) adult trauma patients with interfacility transfer to a higher level of care were included. Patients with missing transport mode or transport time (time from emergency medical service dispatch to patient arrival at the receiving facility) were excluded. Outcome measures were 24-hour and in-hospital mortality. RESULTS: A total of 57,848 severely injured adults who were transferred to a higher level of care were identified. The mean age was 60 ± 20 years. Males accounted for 62%, and the median Injury Severity Score was 17 [16 to 24]. Median transfer time was 126 [92 to 172] minutes, and the most common transport mode was ground ambulance (73%), followed by helicopter ambulance (25%). Every 30-minute delay in transfer time beyond 90 minutes was independently associated with increased odds of 24-hour mortality (adjusted odds ratio 1.042, p = 0.002) and in-hospital mortality (adjusted odds ratio 1.077, p < 0.001). Receiving Level I trauma centers had longer transfer times (128 [94 to 174] vs 124 [88 to 172] minutes; p < 0.001) and higher 24-hour mortality (3.3% vs 2.6%; p < 0.001) and in-hospital mortality (11.2% vs 9.4%; p < 0.001) compared with receiving Level II trauma centers (Figure).Figure.: EMS, emergency medical services.CONCLUSION: Transfer time may be considered a quality-of-care indicator for trauma systems, and transport times for interfacility transferred patients should be kept below 90 minutes. Every half-hour delay in transport time beyond 90 minutes for interfacility transferred patients is associated with 4% and 8% increases in adjusted odds of 24-hour and in-hospital mortality, respectively.
• Joseph, B., Sakran, J. V., Obaid, O., Hosseinpour, H., Ditillo, M., Anand, T., & Zakrison, T. L. (2022). Nationwide Management of Trauma in Child Abuse: Exploring the Racial, Ethnic, and Socioeconomic Disparities. Annals of surgery, 276(3), 500-510.
  More info

  Child abuse is a major cause of childhood injury, morbidity, and death. There is a paucity of data on the practice of abuse interventions among this vulnerable population. The aim of our study was to identify the factors associated with interventions for child abuse on a national scale.
• Joseph, B., Saljuqi, A., Phuong, J., Shipper, E., Braverman, M., Bixby, P., Price, M., Barraco, R., Cooper, Z., Jarman, M., Lack, W., Lueckel, S., Pivalizza, E., Bulger, E., Adams, S., Arbabi, S., Cryer, H., Ditillo, M., Dutton, R., , Fain, M., et al. (2022). Developing a National Trauma Research Action Plan: Results from the geriatric research gap Delphi survey. Journal of Trauma and Acute Care Surgery, 93(2). doi:10.1097/TA.0000000000003626
  More info

  BACKGROUND Treating older trauma patients requires a focus on the confluence of age-related physiological changes and the impact of the injury itself. Therefore, the primary way to improve the care of geriatric trauma patients is through the development of universal, systematic multidisciplinary research. To achieve this, the Coalition for National Trauma Research has developed the National Trauma Research Action Plan that has generated a comprehensive research agenda spanning the continuum of geriatric trauma care from prehospital to rehabilitation. METHODS Experts in geriatric trauma care and research were recruited to identify current gaps in clinical geriatric research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines ensuring heterogeneity and generalizability. On subsequent surveys, participants were asked to rank the priority of each research question on a nine-point Likert scale, categorized to represent low-, medium-, and high-priority items. The consensus was defined as more than 60% of panelists agreeing on the priority category. RESULTS A total of 24 subject matter experts generated questions in 109 key topic areas. After editing for duplication, 514 questions were included in the priority ranking. By round 3, 362 questions (70%) reached 60% consensus. Of these, 161 (44%) were high, 198 (55%) medium, and 3 (1%) low priority. CONCLUSION Among the questions prioritized as high priority, questions related to three types of injuries (i.e., rib fracture, traumatic brain injury, and lower extremity injury) occurred with the greatest frequency. Among the 25 highest priority questions, the key topics with the highest frequency were pain management, frailty, and anticoagulation-related interventions. The most common types of research proposed were interventional clinical trials and comparative effectiveness studies, outcome research, and health care systems research.
• Kapadia, M., Obaid, O., Nelson, A., Hammad, A., Kitts, D. J., Anand, T., Ditillo, M., Douglas, M., & Joseph, B. (2022). Evaluation of Frailty Assessment Compliance in Acute Care Surgery: Changing Trends, Lessons Learned. The Journal of surgical research, 270, 236-244.
  More info

  Routine frailty assessment has emerged recently in the surgical literature and is an important prognostication and risk stratification tool. The aim of our study was to review our 7-y experience with two frailty assessment tools and changing trends in their use.
• Nelson, A., Obaid, O., Hosseinpour, H., Ditillo, M., El-Qawaqzeh, K. W., Stewart, C., Limon, R. F., Nguyen, L., & Joseph, B. (2022). There’s 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, 235(5), S35-S36. doi:10.1097/01.xcs.0000895944.22896.9a
  More info

  Introduction: Guidelines recommend cholecystectomy (CCY) on initial admission, but there is a paucity of large-scale long-term data assessing this approach in the frail geriatric population. Study aims to compare the long-term outcomes of frail geriatric acute biliary pancreatitis (ABP) patients who undergo index CCY vs initial nonoperative management (NOM). Methods: Analysis of the 2017 Nationwide Readmission Database. All frail geriatric patients with ABP were stratified into those who underwent CCY vs NOM during index admission. NOM was defined as those who underwent therapeutic ERCP and did not undergo CCY or cholecystostomy on index admission. Propensity score matching was performed (1:2 ratio). Outcome measures were 6-month readmission, mortality, LOS, and 6-month failure of NOM. Results: 24,341 ABP patients were identified, among whom 7,941 frail geriatric patients were matched (CCY, 5,294; NOM, 2,647). Mean age 74±13 years, 56% female. Matched groups were comparable in baseline characteristics. CCY group had lower 6-month readmission for pancreas-related complication, unplanned readmission for pancreas-related procedures, overall readmission, mortality, and hospitalized days. NOM failed in 12%, and 7% NOM patients were readmitted within 6 months to undergo CCY, of which 56% unplanned. Patients who failed NOM and required unplanned CCY had higher complication (4.5% vs 2.9%, p = 0.027), hospital cost (US $61,718 vs US $55,919, p = 0.002),and mortality (1.6% vs 0.3%, p < 0.001), and longer hospital LOS (5[3-8] vs 4[3-6] days, p < 0.001) compared with CCY on index admission. Conclusion: For frail geriatric patients with ABP, index admission CCY was associated with lower rates of 6-month readmission, pancreas-related complication, need for unplanned pancreas-related procedures, and mortality. One in seven patients failed NOM within 6 months, and one-third of these required an unplanned CCY, with higher complication, cost, and mortality. Early CCY should be prioritized for frail geriatric ABP patients when feasible.
• Nelson, A., Reina, R., Northcutt, A., Obaid, O., Castanon, L., Ditillo, M., Gries, L., Bible, L., Anand, T., & Joseph, B. (2022). Prospective validation of the Rib Injury Guidelines for traumatic rib fractures. The journal of trauma and acute care surgery, 92(6), 967-973.
  More info

  The Rib Injury Guidelines (RIG) were developed to guide triage of traumatic rib fracture patients to home, regular floor, or intensive care unit (ICU) and standardize care. The RIG score is based on patient history, physical examination, and imaging findings. The aim of this study was to evaluate triage effectiveness and health care resources utilization following RIG implementation.
• Nguyen, L., Ditillo, M., Limon, R. F., Anand, T., Hosseinpour, H., Nelson, A., El-Qawaqzeh, K. W., Stewart, C., Obaid, O., & Joseph, B. (2022). Operative Management of Penetrating Colon Injury: Gone Are the Days of the Diverting Colostomy. Journal of the American College of Surgeons, 235(5), S49-S50. doi:10.1097/01.xcs.0000893292.12016.2e
  More info

  INTRODUCTION: There is continued controversy regarding the optimal operative management of penetrating colon injury (PCI). The aim of our study is to compare outcomes of initial diverting operation (DO) vs primary repair and anastomosis (PRA) for PCI. METHODS: A 2017-2018 American College of Surgeons TQIP analysis. All adult trauma patients with operatively managed PCI were included. Transferred, dead ≤24 hours, or burn patients were excluded. Patients were stratified into DO or PRA. Outcomes measures were superficial and deep operative site infection (SSI) rate, intraabdominal abscess, sepsis, infectious complication, and failure of operative management (FOM; unplanned operating room return or subsequent diversion), hospital and ICU length of stay (LOS), and mortality. Multivariate regression was performed to identify predictors of infectious complication. RESULTS: A total of 4,504 patients were identified, of whom 357 (8%) underwent DO and 4,147 (92%) PRA. Mean age was 34 ± 13 years, 4,029(90%) were men, median Injury Severity Score was 16 [9-25]. The most common mechanism of injury was firearm (82%). Left-sided colon was most commonly affected (38%), and 56% had an American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade III PCI or higher. A total of 599b(13%) patients had an infectious complication. DO group had higher superficial SSI rate (5.0% vs 2.4%; p = 0.003) and infectious complication (19.0% v s12.8%; p < 0.001), but no difference in deep SSI rate, intra-abdominal abscess, sepsis, FOM, mortality, hospital and ICU LOS between both groups (p > 0.05). Independent predictors of infectious complication are described in the Table. CONCLUSION: One in 7 patients with PCI developed an infectious complication, most commonly an intra-abdominal abscess. DO is independently associated with increased risk of infectious complication, along with left-sided PCI, concomitant gastric or small intestinal injuries, firearm injury, and AAST-OIS grade of PCI. PRA should be the preferred operative management for PCI.Table
• Obaid, O., Anand, T., Nelson, A., Reina, R., Ditillo, M., Stewart, C., Douglas, M., Friese, R., Gries, L., & Joseph, B. (2022). Fibrinogen supplementation for the trauma patient: Should you choose fibrinogen concentrate over cryoprecipitate?. The journal of trauma and acute care surgery, 93(4), 453-460.
  More info

  Trauma-induced coagulopathy is frequently associated with hypofibrinogenemia. Cryoprecipitate (Cryo), and fibrinogen concentrate (FC) are both potential means of fibrinogen supplementation. The aim of this study was to compare the outcomes of traumatic hemorrhagic patients who received fibrinogen supplementation using FC versus Cryo.
• Reina, R., Anand, T., Bhogadi, S. K., Nelson, A., Hosseinpour, H., Ditillo, M., El-Qawaqzeh, K., Castanon, L., Stewart, C., & Joseph, B. (2022). Nonoperative management of blunt abdominal solid organ injury: Are we paying enough attention to patients on preinjury anticoagulation?. American journal of surgery.
  More info

  This study aims to assess the impact of pre-injury anticoagulant use on outcomes of isolated blunt abdominal SOI patients who underwent NOM.
• Anand, T., Khurrum, M., Chehab, M., Bible, L., Asmar, S., Douglas, M., Ditillo, M., Gries, L., & Joseph, B. (2021). Racial and Ethnic Disparities in Frail Geriatric Trauma Patients. World journal of surgery, 45(5), 1330-1339.
  More info

  Frailty in geriatric trauma patients is commonly associated with adverse outcomes. Racial disparities in geriatric trauma patients are previously described in the literature. We aimed to assess whether race and ethnicity influence outcomes in frail geriatric trauma patients.
• Anand, T., Obaid, O., Nelson, A., Chehab, M., Ditillo, M., Hammad, A., Douglas, M., Bible, L., & Joseph, B. (2021). Whole blood hemostatic resuscitation in pediatric trauma: A nationwide propensity-matched analysis. The journal of trauma and acute care surgery, 91(4), 573-578.
  More info

  Whole blood (WB) has shown promise in pediatric trauma resuscitation following its prominent role in the resuscitation of adult trauma patients. Although WB in children has been shown to be feasible, its effectiveness has yet to be explored. The aim of this study was to examine the outcomes of WB transfusion as an adjunct to component therapy (CT) compared with CT only as early resuscitation for pediatric trauma patients.
• Asmar, S., Bible, L., Chehab, M., Obaid, O., Castanon, L., Yaghi, M., Ditillo, M., & Joseph, B. (2021). Traumatic Femoral Artery Injuries and Predictors of Compartment Syndrome: A Nationwide Analysis. The Journal of surgical research, 265, 159-167.
  More info

  The femoral artery is commonly injured following lower extremity trauma. If not identified early and addressed properly, it can lead to compartment syndrome (CS) and limb amputation. The aim of this study is to examine traumatic femoral artery injuries and identify risk factors for the development of lower extremity CS.
• Asmar, S., Bible, L., Obaid, O., Anand, T., Chehab, M., Ditillo, M., Castanon, L., Nelson, A., & Joseph, B. (2021). Frail geriatric patients with acute calculous cholecystitis: Operative versus nonoperative management?. The journal of trauma and acute care surgery, 91(1), 219-225.
  More info

  Nonoperative management of acute calculous cholecystitis (ACC) in the frail geriatric population is underexplored. The aim of our study was to examine long-term outcomes of frail geriatric patients with ACC treated with cholecystectomy compared with initial nonoperative management.
• Asmar, S., Bible, L., Obaid, O., Tang, A., Khurrum, M., Castanon, L., Ditillo, M., & Joseph, B. (2021). Open vs Endovascular Treatment of Traumatic Peripheral Arterial Injury: Propensity Matched Analysis. Journal of the American College of Surgeons, 233(1), 131-138.e4.
  More info

  Arterial injuries occur in the setting of blunt and penetrating trauma. Despite increasing use, there remains a paucity of data comparing long-term outcomes of endovascular vs open repair management of these injuries. The aim of our study was to compare outcomes and readmission rates of open vs endovascular repair of traumatic arterial injuries.
• Asmar, S., Bible, L., Vartanyan, P., Castanon, L., Masjedi, A., Richards, J., Ditillo, M., Tang, A., & Joseph, B. (2021). Firearm-Related Injuries: A Single Center Experience. The Journal of surgical research, 265, 289-296.
  More info

  Firearm-related injuries (FRI) are an important public health crisis in the US. There is relatively less city level data examining the injury-related trends in Tucson, Arizona. Our study aims to examine FRI, in Southern Arizona's only Level I trauma center.
• Asmar, S., Chehab, M., Bible, L., Khurrum, M., Castanon, L., Ditillo, M., & Joseph, B. (2021). The ED Systolic Blood Pressure Relationship After Traumatic Brain Injury. Journal of Surgical Research, 257. doi:10.1016/j.jss.2020.07.062
  More info

  Background: Blood pressure alterations in patients with traumatic brain injury (TBI) have been shown to be associated with increased mortality. However, there is paucity of data describing the optimal emergency department (ED) systolic blood pressure (SBP) target during the initial evaluation. The aim of our study was to assess the association between SBP on presentation and mortality in patients with TBI. Methods: We performed a retrospective (2015-2016) review of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age ≥18y) trauma patients who had TBI on presentation. The outcome measure was in-hospital mortality at different ED-SBP values. A subanalysis by age and TBI severity in accordance with the Glasgow Coma Scale (GCS) was performed (mild (GCS ≥13), moderate (GCS 9-12), and severe (≤8)). Multivariate logistic regression analysis was performed. Results: A total of 94,411 adult trauma patients with TBI were included. Mean age was 59 ± 21y, 62% were male, and median GCS was 15 [14-15]. Mean SBP was 147 ± 28 mmHg, and overall mortality was 8.6%. The lowest rate of mortality was noticed at ED SBP between 110 and 149 mmHg, whereas the highest mortality was at admission SBP 190 mmHg. On regression analysis, SBP between 130 and 149 mmHg (odds ratio = 0.92; P = 0.68) was not associated with increased odds of mortality relative to SBP between 110 and 129 mmHg. On subanalysis based on severity of TBI (mild 80.9%, moderate 5.3%, and severe 13.8%), patients with SBP between 110 and 149 mmHg were less likely to die across all TBI groups. Conclusions: The optimal ED-SBP range for patients with TBI seems to be age and severity dependent. The optimum range might guide clinicians in developing resuscitation protocols for managing patients with TBI. Level of Evidence: Level III Prognostic.
• Asmar, S., Chehab, M., Bible, L., Khurrum, M., Castañón, L., Ditillo, M., & Joseph, B. (2021). The Emergency Department Systolic Blood Pressure Relationship After Traumatic Brain Injury. Journal of Surgical Research. doi:10.1016/j.jss.2020.07.062
  More info

  Background Blood pressure alterations in patients with traumatic brain injury (TBI) have been shown to be associated with increased mortality. However, there is paucity of data describing the optimal emergency department (ED) systolic blood pressure (SBP) target during the initial evaluation. The aim of our study was to assess the association between SBP on presentation and mortality in patients with TBI. Methods We performed a retrospective (2015-2016) review of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age ≥18y) trauma patients who had TBI on presentation. The outcome measure was in-hospital mortality at different ED-SBP values. A subanalysis by age and TBI severity in accordance with the Glasgow Coma Scale (GCS) was performed (mild (GCS ≥13), moderate (GCS 9-12), and severe (≤8)). Multivariate logistic regression analysis was performed. Results A total of 94,411 adult trauma patients with TBI were included. Mean age was 59 ± 21y, 62% were male, and median GCS was 15 [14-15]. Mean SBP was 147 ± 28 mmHg, and overall mortality was 8.6%. The lowest rate of mortality was noticed at ED SBP between 110 and 149 mmHg, whereas the highest mortality was at admission SBP 190 mmHg. On regression analysis, SBP between 130 and 149 mmHg (odds ratio = 0.92; P = 0.68) was not associated with increased odds of mortality relative to SBP between 110 and 129 mmHg. On subanalysis based on severity of TBI (mild 80.9%, moderate 5.3%, and severe 13.8%), patients with SBP between 110 and 149 mmHg were less likely to die across all TBI groups. Conclusions The optimal ED-SBP range for patients with TBI seems to be age and severity dependent. The optimum range might guide clinicians in developing resuscitation protocols for managing patients with TBI. Level of Evidence Level III Prognostic.
• Asmar, S., Nelson, A., Anand, T., Hammad, A., Obaid, O., Ditillo, M., Saljuqi, T., Tang, A., & Joseph, B. (2021). Marijuana and thromboembolic events in geriatric trauma patients: The cannabinoids clots correlation!. American journal of surgery.
  More info

  Tetrahydrocannabinol (THC) can alter the coagulation cascade resulting in hypercoagulability. The aim of our study is to evaluate the impact of THC use on thromboembolic complications (TEC) in geriatric trauma patients (GTP).
• Calabrese, E. C., Asmar, S., Bible, L., Khurrum, M., Chehab, M., Tang, A., Castanon, L., Ditillo, M., & Joseph, B. (2021). Prospective Evaluation of Health Literacy and Its Impact on Outcomes in Emergency General Surgery. The Journal of surgical research, 261, 343-350.
  More info

  Health literacy (HL) is an important component of national health policy. The aim of our study was to assess the prevalence of low HL (LHL) and determine its impact on outcomes after emergency general surgery (EGS).
• Chehab, M., Bible, L., Obaid, O., Douglas, M., Hammad, A. M., Nelson, A., Ditillo, M., Tang, A., & Joseph, B. (2021). Palliative Care Reduces Long-term Readmissions and Charges in Geriatric Trauma Patients Without Increased Risk of Readmission Mortality. Journal of the American College of Surgeons. doi:10.1016/j.jamcollsurg.2021.07.202
  More info

  Chehab, Mohamad MD; Bible, Letitia MD; Obaid, Omar MD; Douglas, Molly MD; Hammad, Ahmad MD; Nelson, Adam MD; Ditillo, Michael DO; Tang, Andrew MD; Joseph, Bellal MD Author Information
• Chehab, M., Ditillo, M., Khurrum, M., Gries, L., Asmar, S., Douglas, M., Bible, L., Kulvatunyou, N., & Joseph, B. (2021). Managing acute uncomplicated appendicitis in frail geriatric patients: A second hit may be too much. The journal of trauma and acute care surgery, 90(3), 501-506.
  More info

  Studies have proposed the use of antibiotics only in cases of acute uncomplicated appendicitis (AUA). However, there remains a paucity of data evaluating this nonoperative approach in the vulnerable frail geriatric population. The aim of this study was to examine long-term outcomes of frail geriatric patients with AUA treated with appendectomy compared with initial nonoperative management (NOP).
• Chehab, M., Ditillo, M., Obaid, O., Nelson, A., Poppe, B., Douglas, M., Anand, T., Bible, L., & Joseph, B. (2021). Never-frozen liquid plasma transfusion in civilian trauma: a nationwide propensity-matched analysis. The journal of trauma and acute care surgery, 91(1), 200-205.
  More info

  Never-frozen liquid plasma (LQP) was found to reduce component waste, decrease health care expenses, and have a superior hemostatic profile compared with fresh frozen plasma (FFP). Although transfusing LQP in hemorrhaging patients has become more common, its clinical effectiveness remains to be explored. This study aims to examine outcomes of trauma patients transfused with LQP compared with thawed FFP.
• Hamidi, M., Asmar, S., Bible, L., Hanna, K., Castanon, L., Avila, M. J., Ditillo, M., & Joseph, B. (2021). Early Thromboprophylaxis in Operative Spinal Trauma Does Not Increase Risk of Bleeding Complications. Journal of Surgical Research. doi:10.1016/j.jss.2020.08.029
  More info

  Background Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST). Methods We performed a 2014-2017 retrospective analysis of our level I trauma registry and included all adult patients with isolated OST who received low-molecular-weight heparin (LMWH). Patients were stratified into early (≤48 h) and late (>48 h) initiation of LMWH groups. Outcomes were a decline in hemoglobin level, packed red blood cell transfusion, and progression of ISH. We performed multivariable logistic regression. Results We identified a total of 526 patients (early: 332, late: 194). Mean age was 46 ± 22y, and the median spine abbreviated injury scale was 3 [2-4]. After thromboprophylaxis, 1.5% (8) of the patients had progression of ISH and 1% (5) underwent surgical decompression of the spinal canal. There was no difference between the two groups regarding the rate of postprophylaxis ISH progression (1.5% versus 1.6%, P = 0.11) or surgical decompression (0.9% versus 1.1%, P = 0.19). Patients who received LMWH within 48 hrs had a lower incidence of clinically significant deep vein thrombosis (2.4% versus 6.8%, P = 0.02), but no difference in pulmonary embolism (0.6% versus 1.6%, P = 0.33) or mortality (1.2% versus 1.5%, P = 0.41). On regression analysis, there was no difference regarding decline in hemoglobin levels (β = 0.079, [−0.253 to 1.025]; P = 0.23) or number of packed red blood cell units transfused (β = −0.011, [−0.298 to 0.471]; P = 0.35). Conclusions Thromboprophylaxis with LMWH within the first 48 h in patients with OST is safe and efficacious. Prospective studies are needed to further validate their risk-benefit ratio. Level of evidence Level III therapeutic.
• Hamidi, M., Asmar, S., Bible, L., Hanna, K., Castanon, L., Avila, M., Ditillo, M., & Joseph, B. (2021). Early Thromboprophylaxis in Operative Spinal Trauma Does Not Increase Risk of Bleeding Complications. Journal of Surgical Research, 258. doi:10.1016/j.jss.2020.08.029
  More info

  Background: Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST). Methods: We performed a 2014-2017 retrospective analysis of our level I trauma registry and included all adult patients with isolated OST who received low-molecular-weight heparin (LMWH). Patients were stratified into early (≤48 h) and late (>48 h) initiation of LMWH groups. Outcomes were a decline in hemoglobin level, packed red blood cell transfusion, and progression of ISH. We performed multivariable logistic regression. Results: We identified a total of 526 patients (early: 332, late: 194). Mean age was 46 ± 22y, and the median spine abbreviated injury scale was 3 [2-4]. After thromboprophylaxis, 1.5% (8) of the patients had progression of ISH and 1% (5) underwent surgical decompression of the spinal canal. There was no difference between the two groups regarding the rate of postprophylaxis ISH progression (1.5% versus 1.6%, P = 0.11) or surgical decompression (0.9% versus 1.1%, P = 0.19). Patients who received LMWH within 48 hrs had a lower incidence of clinically significant deep vein thrombosis (2.4% versus 6.8%, P = 0.02), but no difference in pulmonary embolism (0.6% versus 1.6%, P = 0.33) or mortality (1.2% versus 1.5%, P = 0.41). On regression analysis, there was no difference regarding decline in hemoglobin levels (β = 0.079, [−0.253 to 1.025]; P = 0.23) or number of packed red blood cell units transfused (β = −0.011, [−0.298 to 0.471]; P = 0.35). Conclusions: Thromboprophylaxis with LMWH within the first 48 h in patients with OST is safe and efficacious. Prospective studies are needed to further validate their risk-benefit ratio. Level of evidence: Level III therapeutic.
• Hanna, K., Asmar, S., Ditillo, M., Chehab, M., Khurrum, M., Bible, L., Douglas, M., & Joseph, B. (2021). Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma. Journal of Surgical Research, 257. doi:10.1016/j.jss.2020.07.060
  More info

  Background: Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. Methods: The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. Results: A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs. On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. Conclusions: MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. Level of Evidence: Level III Prognostic.
• Hanna, K., Asmar, S., Ditillo, M., Chehab, M., Khurrum, M., Bible, L., Douglas, M., & Joseph, B. (2021). Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma. Journal of Surgical Research. doi:10.1016/j.jss.2020.07.060
  More info

  Background Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. Methods The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. Results A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. Conclusions MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. Level of Evidence Level III Prognostic.
• Khurrum, M., Asmar, S., Henry, M. C., Ditillo, M., Chehab, M., Tang, A., Bible, L., Gries, L., & Joseph, B. (2021). The survival benefit of low molecular weight heparin over unfractionated heparin in pediatric trauma patients. Journal of Pediatric Surgery. doi:10.1016/j.jpedsurg.2020.07.021
  More info

  INTRODUCTION Venous thromboembolism (VTE) prophylaxis in pediatric patients is controversial and is mainly dependent on protocols derived from adult practices. Our study aimed to compare outcomes among pediatric trauma patients who received low molecular weight heparin (LMWH) compared to those who received unfractionated heparin (UFH). METHODS We performed 2 years (2015-2016) retrospective analysis of the Pediatrics ACS-TQIP database. Pediatric trauma patients (age ≤17) who received thromboprophylaxis with either LMWH or UFH were included. Patients were stratified into three age groups. Analysis of each subgroup and the entire cohort was performed. Outcome measures included VTE events (deep vein thrombosis [DVT] and pulmonary embolism [PE]), hospital and ICU length of stay (LOS) among survivors, and mortality. Propensity score matching was used to match the two cohorts LMWH vs UFH. RESULTS A matched cohort of 1,678 pediatric trauma patients was analyzed. A significant difference in survival, DVT events, and in-hospital LOS was seen in the age groups above 9 years. Overall, the patients who received LMWH had lower mortality (1.4% vs 3.6%, p
• Khurrum, M., Asmar, S., Henry, M., Ditillo, M., Chehab, M., Tang, A., Bible, L., Gries, L., & Joseph, B. (2021). The survival benefit of low molecular weight heparin over unfractionated heparin in pediatric trauma patients: Survival Benefit of Low Molecular Weight Heparin. Journal of Pediatric Surgery, 56(3). doi:10.1016/j.jpedsurg.2020.07.021
  More info

  Introduction: Venous thromboembolism (VTE) prophylaxis in pediatric patients is controversial and is mainly dependent on protocols derived from adult practices. Our study aimed to compare outcomes among pediatric trauma patients who received low molecular weight heparin (LMWH) compared to those who received unfractionated heparin (UFH). Methods: We performed 2 years (2015–2016) retrospective analysis of the Pediatrics ACS-TQIP database. Pediatric trauma patients (age ≤ 17) who received thromboprophylaxis with either LMWH or UFH were included. Patients were stratified into three age groups. Analysis of each subgroup and the entire cohort was performed. Outcome measures included VTE events (deep vein thrombosis [DVT] and pulmonary embolism [PE]), hospital and ICU length of stay (LOS) among survivors, and mortality. Propensity score matching was used to match the two cohorts LMWH vs UFH. Results: A matched cohort of 1,678 pediatric trauma patients was analyzed. A significant difference in survival, DVT events, and in-hospital LOS was seen in the age groups above 9 years. Overall, the patients who received LMWH had lower mortality (1.4% vs 3.6%, p < 0.01), DVT (1.7% vs 3.7%, p < 0.01), and hospital LOS among survivors (7 days vs 9 days, p < 0.01) compared to those who received UFH. There was no significant difference in the ICU LOS among survivors and the incidence of PE between the two groups. Conclusion: LMWH is associated with increased survival, lower rates of DVT, and decreased hospital LOS compared to UFH among pediatric trauma patients age 10–17 years. Level of Evidence: Level III Prophylactic. Study Type: Prophylactic.
• Khurrum, M., Chehab, M., Ditillo, M., Richards, J., Douglas, M., Bible, L., Spece, L., & Joseph, B. (2021). Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank. The Journal of surgical research, 266, 261-268.
  More info

  Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level.
• Khurrum, M., Ditillo, M., Obaid, O., Anand, T., Nelson, A., Chehab, M., Kitts, D. J., Douglas, M., Bible, L., & Joseph, B. (2021). Four-factor prothrombin complex concentrate in adjunct to whole blood in trauma-related hemorrhage: Does whole blood replace the need for factors?. The journal of trauma and acute care surgery, 91(1), 34-39.
  More info

  The use of whole blood (WB) for the treatment of hemorrhagic shock and coagulopathy is increasing in civilian trauma patients. Four-factor prothrombin complex concentrate (4-PCC) in adjunct to component therapy showed improved outcomes in trauma patients. Our study aims to evaluate the outcomes of trauma patients who received 4-PCC and WB (4-PCC-WB) compared with WB alone.
• Lokhandwala, A., Asmar, S., Khurrum, M., Chehab, M., Bible, L., Castanon, L., Ditillo, M., & Joseph, B. (2021). Platelet Transfusion After Traumatic Intracranial Hemorrhage in Patients on Antiplatelet Agents. Journal of Surgical Research, 257. doi:10.1016/j.jss.2020.07.076
  More info

  Background: With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients. Methods: We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed. Results: A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion. Conclusions: The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients. Level of evidence: Level III prognostic.
• Lokhandwala, A., Asmar, S., Khurrum, M., Chehab, M., Bible, L., Castañón, L., Ditillo, M., & Joseph, B. (2021). Platelet Transfusion After Traumatic Intracranial Hemorrhage in Patients on Antiplatelet Agents. Journal of Surgical Research. doi:10.1016/j.jss.2020.07.076
  More info

  Background With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients. Methods We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed. Results A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion. Conclusions The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients. Level of evidence Level III prognostic.
• Obaid, O., Bible, L., Khurrum, M., Anand, T., Nelson, A., Hammad, A. M., Douglas, M., Ditillo, M., Tang, A., & Joseph, B. (2021). Optimal Operative Approach for Emergent Inguinal Hernia Repair: A Nationwide Outcomes-based Analysis. Journal of the American College of Surgeons. doi:10.1016/j.jamcollsurg.2021.08.134
• Obaid, O., Hammad, A., Bible, L., Ditillo, M., Castanon, L., Douglas, M., Anand, T., Nelson, A., & Joseph, B. (2021). Open Versus Laparoscopic Repair of Traumatic Diaphragmatic Injury: A Nationwide Propensity-Matched Analysis. The Journal of surgical research, 268, 452-458.
  More info

  Minimally invasive surgical techniques have become routinely applied in the evaluation and treatment of patients with isolated traumatic diaphragmatic injuries (TDI). However, there remains a paucity of data that compares the laparoscopic repair to the open repair approach. The aim of our study is to examine patient outcomes between TDI patients managed laparoscopically versus those managed using open repair.
• Saljuqi, A. T., Khurrum, M., Obaid, O., Anand, T., Douglas, M., Ditillo, M., Bible, L., Nelson, A., Castañón, L., & Joseph, B. (2021). The Impact of Cannabinoid Consumption on Outcomes of Geriatric Rib Fracture Patients: A Nationwide Propensity-Matched Analysis. Journal of the American College of Surgeons. doi:10.1016/j.jamcollsurg.2021.07.585
  More info

  Saljuqi, Abdul Tawab MD; Khurrum, Muhammad MD; Obaid, Omar; Anand, Tanya MD; Douglas, Molly MD; Ditillo, Michael F. DO, FACS; Bible, Letitia; Nelson, Adam; Castanon, Lourdes; Joseph, Bellal Author Information
• Anand, T., Hanna, K., Kulvatunyou, N., Zeeshan, M., Ditillo, M., Castanon, L., Tang, A., Gries, L., & Joseph, B. (2020). Time to tracheostomy impacts overall outcomes in patients with cervical spinal cord injury. The journal of trauma and acute care surgery, 89(2), 358-364.
  More info

  The morbidity associated with cervical spine injury increases in the setting of concomitant cervical spinal cord injury (CSCI). A significant proportion of these patients require placement of a tracheostomy. However, it remains unclear if timing to tracheostomy following traumatic CSCI can impact outcomes. The aim of our study was to characterize outcomes associated with tracheostomy timing following traumatic CSCI.
• Asmar, S., Bible, L., Chehab, M., Tang, A., Khurrum, M., Castañón, L., Ditillo, M., Douglas, M., & Joseph, B. (2020). Traumatic brain injury induced temperature dysregulation: What is the role of β blockers?. The Journal of Trauma and Acute Care Surery. doi:10.1097/ta.0000000000002975
  More info

  Traumatic brain injury (TBI) is associated with sympathetic discharge that leads to posttraumatic hyperthermia (PTH). Beta blockers (ββ) are known to counteract overactive sympathetic discharge. The aim of our study was to evaluate the effect of ββ on PTH in critically-ill TBI patients.We performed retrospective cohort analysis of the Medical Information Mart for Intensive Care database. We included all critically ill TBI patients with head Abbreviated Injury Scale (AIS) score of 3 or greater and other body region AIS score less than 2 who developed PTH (at least one febrile episode [T > 38.3°C] with negative microbiological cultures (blood, urine, and bronchoalveolar lavage). Patients on preinjury ββ were excluded. Patients were stratified into (ββ+) and (ββ-) groups. Propensity score matching was performed (1:1 ratio) controlling for patient demographics, injury parameters and other medications that influence temperature. Outcomes were the number of febrile episodes, maximum temperature, and the time interval between febrile episodes. Multivariate linear regression was performed.We analyzed 4,286 critically ill TBI patients. A matched cohort of 1,544 patients was obtained: 772 ββ + (metoprolol, 60%; propranolol, 25%; and atenolol, 15%) and 772 ββ-. Mean age was 63.4 ± 15.4 years, median head AIS score of 3 (3-4), and median Injury Severity Score of 10 (9-16). Patients in the ββ+ group had a lower number of febrile episodes (8 episodes vs. 12 episodes; p = 0.003), lower median maximum temperature (38.0°C vs. 38.5°C; p = 0.025), and a longer median time between febrile episodes (3 hours vs. 1 hour; p = 0.013). On linear regression, propranolol was found to be superior in terms of reducing the number of febrile episodes and the maximum temperature. However, there was no significant difference between the three ββ in terms of reducing the time interval between febrile episodes (p = 0.582).Beta blockers attenuate PTH by decreasing the frequency of febrile episodes, increasing the time interval between febrile episodes, and reducing the maximum rise in temperature. ββ may be a potential therapeutic modality in PTH.Therapeutic, level IV.
• Asmar, S., Chehab, M., Bible, L., Khurrum, M., Castanon, L., Ditillo, M., & Joseph, B. (2020). The ED Systolic Blood Pressure Relationship After Traumatic Brain Injury. The Journal of surgical research, 257, 493-500.
  More info

  Blood pressure alterations in patients with traumatic brain injury (TBI) have been shown to be associated with increased mortality. However, there is paucity of data describing the optimal emergency department (ED) systolic blood pressure (SBP) target during the initial evaluation. The aim of our study was to assess the association between SBP on presentation and mortality in patients with TBI.
• Asmar, S., Lokhandwala, A., Richards, J., Bible, L., Avila, M., Castanon, L., Ditillo, M., Douglas, M., & Joseph, B. (2020). The neuroprotective effect of quetiapine in critically ill traumatic brain injury patients. The journal of trauma and acute care surgery, 89(4), 775-782.
  More info

  Quetiapine is an atypical antipsychotic commonly used in critical care. Cellular and animal models demonstrated its novel anti-inflammatory properties in traumatic brain injury (TBI). Our study aimed to assess the effect of quetiapine on outcomes in critically ill TBI patients. We hypothesize that quetiapine improves neurological outcomes.
• Astarabadi, M., Khurrum, M., Asmar, S., Bible, L., Chehab, M., Castanon, L., Ditillo, M., Douglas, M., & Joseph, B. (2020). The impact of non-neurological organ dysfunction on outcomes in severe isolated traumatic brain injury. The journal of trauma and acute care surgery, 89(2), 405-410.
  More info

  Organ dysfunction following traumatic brain injury (TBI) is common and has been associated with unpredictable outcomes. The aim of our study is to describe the incidence of non-neurological organ dysfunction (NNOD) and its impact on outcomes in patients with severe TBI admitted to our intensive care unit (ICU).
• Castanon, L., Asmar, S., Bible, L., Chehab, M., Ditillo, M., Khurrum, M., Hanna, K., Douglas, M., & Joseph, B. (2020). Early Enteral Nutrition in Geriatric Burn Patients: Is There a Benefit?. Journal of burn care & research : official publication of the American Burn Association, 41(5), 986-991.
  More info

  Nutrition is a critical component of acute burn care and wound healing. There is no consensus over the appropriate timing of initiating enteral nutrition in geriatric burn patients. This study aimed to assess the impact of early enteral nutrition on outcomes in this patient population. We performed a 1-year (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program and included all older adult (age ≥65 years) isolated thermal burn patients who were admitted for more than 24 hr and received enteral nutrition. Patients were stratified into two groups based on the timing of initiation of feeding: early (≤24 hr) vs late (>24 hr). Multivariate logistic regression was performed to control for potential confounding factors. Outcome measures were hospital and intensive care unit lengths of stay, in-hospital complications, and mortality. A total of 1,004,440 trauma patients were analyzed, of which 324 patients were included (early: 90 vs late: 234). The mean age was 73.9 years and mean TBSA burnt was 31%. Patients in the early enteral nutrition group had significantly lower rates of in-hospital complications and mortality (15.6% vs 26.1%; P = 0.044), and a shorter hospital length of stay (17 [11,23] days vs 20 [14,24] days; P = 0.042) and intensive care unit length of stay (13 [8,15] days vs 17 [9,21] days; P = 0.042). In our regression model of geriatric burn patients, early enteral nutrition was associated with improved outcomes. The cumulative benefits observed may warrant incorporating early enteral nutrition as part of intensive care protocols.
• Chehab, M., Afaneh, A., Bible, L., Castanon, L., Hanna, K., Ditillo, M., Khurrum, M., Asmar, S., & Joseph, B. (2020). Angioembolization in intra-abdominal solid organ injury: Does delay in angioembolization affect outcomes?. The journal of trauma and acute care surgery, 89(4), 723-729.
  More info

  Angioembolization (AE) is an integral component in multidisciplinary algorithms for achieving hemostasis in patients with trauma. The American College of Surgeons Committee on Trauma recommends that interventional radiologists be available within 30 minutes to perform emergent AE. However, the impact of the timing of AE on patient outcomes is still not well known. We hypothesized that a delay in AE would be associated with increased mortality and higher blood transfusion requirements in patients with blunt intra-abdominal solid organ injury.
• Chehab, M., Ditillo, M., Khurrum, M., Gries, L., Asmar, S., Douglas, M., Bible, L., Kulvatunyou, N., & Joseph, B. (2020). Managing acute uncomplicated appendicitis in frail geriatric patients: A second hit may be too much. The Journal of Trauma and Acute Care Surgery. doi:10.1097/ta.0000000000003028
  More info

  Studies have proposed the use of antibiotics only in cases of acute uncomplicated appendicitis (AUA). However, there remains a paucity of data evaluating this nonoperative approach in the vulnerable frail geriatric population. The aim of this study was to examine long-term outcomes of frail geriatric patients with AUA treated with appendectomy compared with initial nonoperative management (NOP).We conducted a 1-year (2017) analysis of the Nationwide Readmissions Database and included all frail geriatric patients(age, ≥65 years) with a diagnosis of AUA. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing appendectomy at index admission (operative management) versus those receiving antibiotics only without operative intervention (NOP). Propensity score matching in a 1:1 ratio was performed adjusting for patient- and hospital-related factors.A total of 5,562 frail geriatric patients with AUA were identified from which a matched cohort of 1,320 patients in each group was obtained. Patients in the NOP and operative management were comparable in terms of age (75.5 ± 7.7 vs. 75.5 ± 7.4 years; p = 0.882) and modified frailty index (0.4 [0.4-0.6] vs. 0.4 [0.4-0.6]; p = 0.526). Failure of NOP management was reported in 18% of patients, 95% of which eventually underwent appendectomy. Over the 6-month follow-up period, patients in the NOP group had significantly higher rates of Clostridium difficile enterocolitis (3% vs. 1%; p < 0.001), greater number of overall hospitalized days (5 [3-9] vs. 4 [2-7] days; p < 0.001), and higher overall costs (US $16,000 [12,000-25,000] vs. US $11,000 [8,000-19,000]; p < 0.001). Patients undergoing appendectomy after failed NOP had significantly higher rates of complications (20% vs. 11%; p < 0.001), mortality (4% vs. 2%; p = 0.019), and appendiceal neoplasm (3% vs. 1%; p = 0.027).One in six patients failed NOP within 6 months and required appendectomy with subsequent more complications and higher mortality. Appendectomy may offer better outcomes in managing AUA in the frail geriatric population.Therapeutic, level IV.
• Cragun, B. N., Noorbakhsh, M. R., Hite Philp, F., Suydam, E. R., Ditillo, M. F., Philp, A. S., & Murdock, A. D. (2020). Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Finding. The Journal of surgical research, 249, 99-103.
  More info

  Guidelines for management of intracranial hemorrhage do not account for bleed location. We hypothesize that parafalcine subdural hematoma (SDH), as compared to convexity SDH, is a distinct clinical entity and these patients do not benefit from critical care monitoring or repeat imaging.
• Ditillo, M., Hanna, K., Castanon, L., Zeeshan, M., Kulvatunyou, N., Tang, A., Sakran, J., Gries, L., & Joseph, B. (2020). The role of cryoprecipitate in massively transfused patients: Results from the Trauma Quality Improvement Program database may change your mind. The journal of trauma and acute care surgery, 89(2), 336-343.
  More info

  Cryoprecipitate was developed for the treatment of inherited and acquired coagulopathies. The role of cryoprecipitate in hemorrhaging trauma patients is still speculative. The aim of our study was to assess the role of cryoprecipitate as an adjunct to transfusion in trauma patients.
• Ditillo, M., Saljuqi, A. T., & Asmar, S. (2020). Delirium in Geriatric Trauma Patients. Current Trauma Reports. doi:10.1007/s40719-020-00204-8
• Hamidi, M., Asmar, S., Bible, L., Hanna, K., Castanon, L., Avila, M., Ditillo, M., & Joseph, B. (2020). Early Thromboprophylaxis in Operative Spinal Trauma Does Not Increase Risk of Bleeding Complications. The Journal of surgical research, 258, 119-124.
  More info

  Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST).
• Hanna, K., Asmar, S., Ditillo, M., Chehab, M., Khurrum, M., Bible, L., Douglas, M., & Joseph, B. (2020). Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma. The Journal of surgical research, 257, 69-78.
  More info

  Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT.
• Hanna, K., Bible, L., Chehab, M., Asmar, S., Douglas, M., Ditillo, M., Castanon, L., Tang, A., & Joseph, B. (2020). Nationwide analysis of whole blood hemostatic resuscitation in civilian trauma. The journal of trauma and acute care surgery, 89(2), 329-335.
  More info

  Renewed interest in whole blood (WB) resuscitation in civilians has emerged following its military use. There is a paucity of data on its role in civilians where balanced component therapy (CT) resuscitation is the standard of care. The aim of this study was to assess nationwide outcomes of using WB as an adjunct to CT versus CT alone in resuscitating civilian trauma patients.
• Hanna, K., Chehab, M., Bible, L., Asmar, S., Ditillo, M., Castanon, L., Tang, A., & Joseph, B. (2020). Failure to Rescue in Emergency General Surgery: Impact of Fragmentation of Care. Annals of surgery.
  More info

  Compare emergency general surgery (EGS) patient outcomes following index and non-index hospital readmissions, and explore predictive factors for non-index readmission.
• Hanna, K., Chehab, M., Bible, L., Asmar, S., Ditillo, M., Castañón, L., Tang, A., & Joseph, B. (2020). Failure to Rescue in Emergency General Surgery. Annals of Surgery. doi:10.1097/sla.0000000000004628
  More info

  Compare EGS patient outcomes after index and nonindex hospital readmissions, and explore predictive factors for nonindex readmission.Readmission to a different hospital leads to fragmentation of care. The impact of nonindex readmission on patient outcomes after EGS is not well established.The Nationwide Readmissions Database (2017) was queried for adult patients readmitted after an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index versus nonindex hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital length of stay, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors.A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) versus nonindex hospital (17,655; 22.3%). After 1:1 propensity matching, patients with nonindex readmission had higher rates of FTR (5.6% vs 4.3%; P < 0.001), mortality (2.7% vs 2.1%; P < 0.001), and overall hospital costs [in $1000; 37 (27-64) vs 28 (21-48); P < 0.001]. Nonindex readmission was independently associated with higher odds of FTR [adjusted odds ratio 1.18 (1.03-1.36); P < 0.001]. Predictors of nonindex readmission included top quartile for zip code median household income [1.35 (1.08-1.69); P < 0.001], fringe county residence [1.08 (1.01-1.16); P = 0.049], discharge to a skilled nursing facility [1.28 (1.20-1.36); P < 0.001], and leaving against medical advice [2.32 (1.81-2.98); P < 0.001].One in 5 readmissions after EGS occur at a different hospital. Nonindex readmission carries a heightened risk of FTR.Level III Prognostic.Prognostic.
• Hanna, K., Chehab, M., Bible, L., Castanon, L., Douglas, M., Asmar, S., Ditillo, M., Tang, A., & Joseph, B. (2020). Nationwide analysis of cryopreserved packed red blood cell transfusion in civilian trauma. The journal of trauma and acute care surgery, 89(5), 861-866.
  More info

  Liquid packed red blood cells (LPRBCs) have a limited shelf life and worsening quality with age. Cryopreserved packed red blood cells (CPRBCs) can be stored up to 10 years with no quality deterioration. The effect of CPRBCs on outcomes in civilian trauma is less explored. This study aims to evaluate the safety and efficacy of CPRBCs in civilian trauma patients.
• Hanna, K., Douglas, M., Asmar, S., Khurrum, M., Bible, L., Castanon, L., Ditillo, M., Kulvatunyou, N., & Joseph, B. (2020). Treatment of blunt cerebrovascular injuries: Anticoagulants or antiplatelet agents?. The journal of trauma and acute care surgery, 89(1), 74-79.
  More info

  Blunt cerebrovascular injury (BCVI) is associated with cerebrovascular accidents (CVA). Early therapy with antiplatelet agents or anticoagulants is recommended. There are limited data comparing the effectiveness of these treatments. The aim of our study was to compare outcomes between BCVI patients who received anticoagulants versus those who received antiplatelet agents.
• Hanna, K., Khan, M., Ditillo, M., Hamidi, M., Tang, A., Zeeshan, M., Saljuqi, A. T., & Joseph, B. (2020). Prospective evaluation of preoperative cognitive impairment and postoperative morbidity in geriatric patients undergoing emergency general surgery. American journal of surgery, 220(4), 1064-1070.
  More info

  Cognitive impairment (CI) is common in geriatric patients. We aimed to evaluate the prevalence and impact of CI on outcomes in geriatric patients undergoing emergency general surgery (EGS).
• Khurrum, M., Asmar, S., Henry, M., Ditillo, M., Chehab, M., Tang, A., Bible, L., Gries, L., & Joseph, B. (2020). The survival benefit of low molecular weight heparin over unfractionated heparin in pediatric trauma patients. Journal of pediatric surgery.
  More info

  Venous thromboembolism (VTE) prophylaxis in pediatric patients is controversial and is mainly dependent on protocols derived from adult practices. Our study aimed to compare outcomes among pediatric trauma patients who received low molecular weight heparin (LMWH) compared to those who received unfractionated heparin (UFH).
• Lokhandwala, A. M., Asmar, S., Khurrum, M., Chehab, M., Bible, L., Castanon, L., Ditillo, M., & Joseph, B. (2020). Platelet Transfusion After Traumatic Intracranial Hemorrhage in Patients on Antiplatelet Agents. The Journal of surgical research, 257, 239-245.
  More info

  With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients.
• Lokhandwala, A., Hanna, K., Gries, L., Zeeshan, M., Ditillo, M., Tang, A., Hamidi, M., & Joseph, B. (2020). Preinjury Statins Are Associated With Improved Survival in Patients With Traumatic Brain Injury. Journal of Surgical Research, 245. doi:10.1016/j.jss.2019.07.081
  More info

  Background: Statins have been shown to improve outcomes in traumatic brain injury (TBI) in animal models. The aim of our study was to determine the effect of preinjury statins on outcomes in TBI patients. Methods: We performed a 4-y (2014-2017) review of our TBI database and included all patients aged ≥18 y with severe isolated TBI. Patients were stratified into those who were on statins and those who were not and were matched (1:2 ratio) using propensity score matching. The primary outcome was in-hospital mortality. The secondary outcomes were skilled nursing facility disposition, Glasgow Outcome Scale–extended score, and hospital and intensive care unit length of stay (LOS). Results: We identified 1359 patients, of which 270 were matched (statin: 90, no-statin: 180). Mean age was 55 ± 8y, median Glasgow Coma Scale was 10 (8-12), and median head–abbreviated injury scale was 3 (3-5). Matched groups were similar in age, mechanism of injury, Glasgow Coma Scale, Injury Severity Score, neurosurgical intervention, type and size of intracranial hemorrhage, and preinjury anticoagulant or antiplatelet use. The overall in-hospital mortality rate was 18%. Patients who received statins had lower rates of in-hospital mortality (11% versus 21%, P = 0.01), skilled nursing facility disposition (19% versus 28%; P = 0.04), and a higher median Glasgow Outcome Scale–extended (11 [9-13] versus 9 [8-10]; P = 0.04). No differences were found between the two groups in terms of hospital LOS (6 [4-9] versus 5 [3-8]; P = 0.34) and intensive care unit LOS (3 [3-6] versus 4 [3-5]; P = 0.09). Conclusions: Preinjury statin use in isolated traumatic brain injury patients is associated with improved outcomes. This finding warrants further investigations to evaluate the potential beneficial role of statins as a therapeutic drug in a TBI. Level of evidence: Level III Therapeutic.
• Lokhandwala, A., Hanna, K., Gries, L., Zeeshan, M., Ditillo, M., Tang, A., Hamidi, M., & Joseph, B. (2020). Preinjury Statins Are Associated With Improved Survival in Patients With Traumatic Brain Injury. Journal of Surgical Research. doi:10.1016/j.jss.2019.07.081
  More info

  Statins have been shown to improve outcomes in traumatic brain injury (TBI) in animal models. The aim of our study was to determine the effect of preinjury statins on outcomes in TBI patients.We performed a 4-y (2014-2017) review of our TBI database and included all patients aged ≥18 y with severe isolated TBI. Patients were stratified into those who were on statins and those who were not and were matched (1:2 ratio) using propensity score matching. The primary outcome was in-hospital mortality. The secondary outcomes were skilled nursing facility disposition, Glasgow Outcome Scale-extended score, and hospital and intensive care unit length of stay (LOS).We identified 1359 patients, of which 270 were matched (statin: 90, no-statin: 180). Mean age was 55 ± 8y, median Glasgow Coma Scale was 10 (8-12), and median head-abbreviated injury scale was 3 (3-5). Matched groups were similar in age, mechanism of injury, Glasgow Coma Scale, Injury Severity Score, neurosurgical intervention, type and size of intracranial hemorrhage, and preinjury anticoagulant or antiplatelet use. The overall in-hospital mortality rate was 18%. Patients who received statins had lower rates of in-hospital mortality (11% versus 21%, P = 0.01), skilled nursing facility disposition (19% versus 28%; P = 0.04), and a higher median Glasgow Outcome Scale-extended (11 [9-13] versus 9 [8-10]; P = 0.04). No differences were found between the two groups in terms of hospital LOS (6 [4-9] versus 5 [3-8]; P = 0.34) and intensive care unit LOS (3 [3-6] versus 4 [3-5]; P = 0.09).Preinjury statin use in isolated traumatic brain injury patients is associated with improved outcomes. This finding warrants further investigations to evaluate the potential beneficial role of statins as a therapeutic drug in a TBI.Level III Therapeutic.
• Masjedi, A., Asmar, S., Bible, L., Khurrum, M., Chehab, M., Castanon, L., Ditillo, M., & Joseph, B. (2020). The Evolution of Nonoperative Management of Abdominal Gunshot Wounds in the United States. The Journal of surgical research, 253, 224-231.
  More info

  Surgical exploration for gunshot wounds to the abdomen has been a surgical standard for the greater part of the past century. Recently, nonoperative management (NOM) has been deemed as a safe option for abdominal gunshot wounds (AGWs). The aim of this analysis was to review the utilization of NOM and mortality after AGWs.
• Saljuqi, A. T., Hanna, K., Asmar, S., Tang, A., Zeeshan, M., Gries, L., Ditillo, M., Kulvatunyou, N., Castanon, L., & Joseph, B. (2020). Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery. Journal of the American College of Surgeons, 230(5), 758-765.
  More info

  The prevalence of delirium and its impact on outcomes after emergency general surgery (EGS) remain unexplored. The aims of our study were to assess the impact of frailty on delirium and the impact of delirium on outcomes in geriatric EGS patients.
• Stupinski, J., Bible, L., Asmar, S., Chehab, M., Douglas, M., Ditillo, M., Gries, L., Khurrum, M., & Joseph, B. (2020). Impact of marijuana on venous thromboembolic events: Cannabinoids cause clots in trauma patients. The journal of trauma and acute care surgery, 89(1), 125-131.
  More info

  Tetrahydrocannabinoids (THC) can modulate the coagulation cascade resulting in hypercoagulability. However, the clinical relevance of these findings has not been investigated. The aim of our study was to evaluate the impact of preinjury marijuana exposure on thromboembolic complications (TEC) in trauma patients.
• Tang, A., Chehab, M., Ditillo, M., Asmar, S., Khurrum, M., Douglas, M., Bible, L., Kulvatunyou, N., & Joseph, B. (2020). Regionalization of Trauma Care by Operative Experience: Does the Volume of Emergent Laparotomy Matter?. The journal of trauma and acute care surgery.
  More info

  The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients.
• Tang, A., Chehab, M., Ditillo, M., Asmar, S., Khurrum, M., Douglas, M., Bible, L., Kulvatunyou, N., & Joseph, B. (2020). Regionalization of trauma care by operative experience: Does the volume of emergent laparotomy matter?. The Journal of Trauma and Acute Surgery. doi:10.1097/ta.0000000000002911
  More info

  INTRODUCTION The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers’ injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center’s injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients. METHODS We performed a (2017) analysis of the Trauma Quality Improvement Program database. We included adult (age, ≥18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: high volume (HV), ≥25 cases per year; medium volume (MV), 13 to 24 cases per year; and low volume (LV), ≤12 cases per year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality. RESULTS A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean ± SD age was 40 ± 17 years, abdomen Abbreviated Injury Scale was 3 (2–4), and Injury Severity Score was 26 (17–35). For American College of Surgeons (ACS) level I centers, 50% were HV; 29%, MV; and 21%, LV. For ACS level II centers, 7% were HV; 23%, MV; and 70%, LV. For ACS level III centers, 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. High-volume blunt centers had a significantly lower time to laparotomy (72 [41–144] minutes) versus MV (81 [49–145] minutes) and LV (94 [56–158] minutes) centers ( p < 0.001). The same trend was observed for HV penetrating trauma centers (35 [24–52] minutes) versus MV (46 [33–63] minutes) and LV (51 [38–69] minutes) centers ( p < 0.001). CONCLUSION Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers’ injury-specific operative experience. LEVEL OF EVIDENCE Prognostic, Level III; Therapeutic/Care management, Level IV.
• Vartan, P., Asmar, S., Bible, L., Chehab, M., Khurrum, M., Castanon, L., Ditillo, M., & Joseph, B. (2020). Alcohol Use Disorder Is Bad for Broken Ribs: A Nationwide Analysis of 19,638 Patients With Rib Fractures. The Journal of surgical research, 255, 556-564.
  More info

  Alcohol use disorder (AUD) has deleterious effects on many organ systems. The aim of our study was to assess the impact of AUD on outcomes in patients with rib fractures. We hypothesized that AUD is associated with increased risk adverse outcomes.
• Anand, T., Haddadin, Z., Tang, A., Saljuqi, A. T., Hamidi, M., Ditillo, M., Kulvatunyou, N., Gries, L., Northcutt, A., & Joseph, B. (2019). Association of Racial, Ethnic Disparities, and Frailty in Geriatric Trauma Patients. World Journal of Surgery. doi:10.1016/j.jamcollsurg.2019.08.265
  More info

  Anand, Tanya MD; Haddadin, Zaid MD; Tang, Andrew L. MD, FACS; Saljuqi, Abdul Tawab K. MD, MPH; Hamidi, Mohammad K. MD; Ditillo, Michael DO, FACS; Kulvatunyou, Narong MD, FACS; Gries, Lynn M. MD, FACS; Northcutt, Ashley MD; Joseph, Bellal MD, FACS Author Information
• Cragun, B., Hite Philp, F., O'neill, J., Noorbakhsh, M., Tindall, R., Philp, A., & Ditillo, M. (2019). Therapeutic Hypothermia and Targeted Temperature Management for Traumatic Arrest and Surgical Patients. Therapeutic Hypothermia and Temperature Management, 9(2). doi:10.1089/ther.2018.0022
  More info

  Therapeutic hypothermia (TH) and targeted temperature management (TTM) have been shown to improve outcomes in survivors of cardiac arrest, but prior research has excluded trauma and postoperative patients. We sought to determine whether TH/TTM is safe in trauma and surgical patients. A retrospective cohort study was conducted at a single level I trauma center reviewing adults presenting as a traumatic arrest or cardiac arrest in the postoperative period with a Glasgow Coma Scale
• Cragun, B., Philp, F. H., O’Neill, J., Noorbakhsh, M. R., Tindall, R. P., Philp, A., & Ditillo, M. (2019). Therapeutic Hypothermia and Targeted Temperature Management for Traumatic Arrest and Surgical Patients. Therapeutic Hypothermia and Temperature Management. doi:10.1089/ther.2018.0022
  More info

  Therapeutic hypothermia (TH) and targeted temperature management (TTM) have been shown to improve outcomes in survivors of cardiac arrest, but prior research has excluded trauma and postoperative patients. We sought to determine whether TH/TTM is safe in trauma and surgical patients. A retrospective cohort study was conducted at a single level I trauma center reviewing adults presenting as a traumatic arrest or cardiac arrest in the postoperative period with a Glasgow Coma Scale
• Haddadin, Z., Hanna, K., Castañón, L., Zeeshan, M., Ditillo, M., Tang, A., Gries, L., Hamidi, M., Kulvatunyou, N., & Joseph, B. (2019). Rib Plating the Non-Flail Chest May Not Be as Good as You Think. Journal of the American College of Surgeons. doi:10.1016/j.jamcollsurg.2019.08.1396
  More info

  Haddadin, Zaid MD; Hanna, Kamil MD; Castanon, Lourdes MD; Zeeshan, Muhammad MD; Ditillo, Michael DO, FACS; Tang, Andrew MD, FACS; Gries, Lynn M. MD, FACS; Hamidi, Mohammad K. MD; Kulvatunyou, Narong MD, FACS; Joseph, Bellal MD, FACS Author Information
• Haddadin, Z., Hanna, K., Gries, L., Zeeshan, M., Tang, A., Ditillo, M., Castañón, L., Hamidi, M., Kulvatunyou, N., & Joseph, B. (2019). Evolution of Nonoperative Management of Abdominal Gunshot Wounds in the US: Analysis of 16,866 Abdominal Gunshot Wounds. Journal of Surgical Research JSR. doi:10.1016/j.jamcollsurg.2019.08.646
  More info

  Haddadin, Zaid MD; Hanna, Kamil MD; Gries, Lynn M. MD, FACS; Zeeshan, Muhammad MD; Tang, Andrew MD, FACS; Ditillo, Michael DO, FACS; Castanon, Lourdes MD; Hamidi, Mohammad K. MD; Kulvatunyou, Narong MD, FACS; Joseph, Bellal MD, FACS Author Information
• Hamidi, M., Hanna, K., Gries, L., Zeeshan, M., Haddadin, Z., O’Keeffe, T., Ditillo, M., Northcutt, A., Tang, A., & Joseph, B. (2019). Early Initiation of Thromboprophylaxis in Operative Spine Trauma Does Not Increase the Risk of Bleeding Complication. Journal of Surgical Research. doi:10.1016/j.jamcollsurg.2019.08.428
  More info

  Hamidi, Mohammad K. MD; Hanna, Kamil MD; Gries, Lynn M. MD, FACS; Zeeshan, Muhammad MD; Haddadin, Zaid MD; O’Keeffe, Terence MD, FACS; Ditillo, Michael DO, FACS; Northcutt, Ashley MD; Tang, Andrew L. MD, FACS; Joseph, Bellal MD, FACS Author Information
• Hanna, K., Ditillo, M., & Joseph, B. (2019). The role of frailty and prehabilitation in surgery. Current opinion in critical care, 25(6), 717-722.
  More info

  The aging surgical population constitutes a unique challenge to clinicians across the spectrum of care. Frailty is a valuable tool for preoperative risk stratification and may guide targeted interventions, such as prehabilitation. The aim of this review is to revise the recent literature on the role of frailty and prehabilitation to optimize geriatric patients undergoing surgery.
• Hanna, K., Haddadin, Z., Ditillo, M., Hamidi, M., O’Keeffe, T., Zeeshan, M., Gries, L., Tang, A., Kulvatunyou, N., & Joseph, B. (2019). Readmission with Major Abdominal Complications after Penetrating Abdominal Trauma. Journal of Surgical Research. doi:10.1016/j.jamcollsurg.2019.08.671
  More info

  Hanna, Kamil MD; Haddadin, Zaid MD; Ditillo, Michael DO, FACS; Hamidi, Mohammad K. MD; O’Keeffe, Terence MD, FACS; Zeeshan, Muhammad MD; Gries, Lynn M. MD, FACS; Tang, Andrew L. MD, FACS; Kulvatunyou, Narong MD; Joseph, Bellal MD, FACS Author Information
• Hanna, K., Hamidi, M., Anderson, K. T., Ditillo, M., Zeeshan, M., Tang, A., Henry, M., Kulvatunyou, N., & Joseph, B. (2019). Pediatric resuscitation: Weight-based packed red blood cell volume is a reliable predictor of mortality. The journal of trauma and acute care surgery, 87(2), 356-363.
  More info

  The definition of massive transfusion (MT) in civilian pediatric trauma patients is not established. In combat-injured pediatric patients, the definition of MT is based on the volume of total blood products transfused. The aim of this study is to define MT in civilian pediatric trauma patients based on a packed red blood cell (PRBC) volume threshold and compare its predictive power to a total blood products volume threshold.
• Kapadia, M., Hanna, K., Northcutt, A., Saljuqi, A. T., Ditillo, M., Gries, L., Kulvatunyou, N., Hamidi, M., Castañón, L., & Joseph, B. (2019). Prospective Evaluation of Frailty Assessment Compliance in Acute Care Surgery: Changing Trends, Lessons Learned. Journal of Surgical Research. doi:10.1016/j.jamcollsurg.2019.08.271
  More info

  Kapadia, Meera MS; Hanna, Kamil MD; Northcutt, Ashley MD; Saljuqi, Abdul Tawab K. MD, MPH; Ditillo, Michael DO, FACS; Gries, Lynn M. MD, FACS; Kulvatunyou, Narong MD; Hamidi, Mohammad K. MD; Castanon, Lourdes MD; Joseph, Bellal MD, FACS Author Information
• Lokhandwala, A., Hanna, K., Gries, L., Zeeshan, M., Ditillo, M., Tang, A., Hamidi, M., & Joseph, B. (2019). Preinjury Statins Are Associated With Improved Survival in Patients With Traumatic Brain Injury. The Journal of surgical research, 245, 367-372.
  More info

  Statins have been shown to improve outcomes in traumatic brain injury (TBI) in animal models. The aim of our study was to determine the effect of preinjury statins on outcomes in TBI patients.
• Lokhandwala, A., Hanna, K., Haddadin, Z., O’Keeffe, T., Zeeshan, M., Hamidi, M., Joseph, B., Gries, L., Ditillo, M., & Northcutt, A. (2019). Strict Resuscitation Strategies Improve Outcomes in Patients with Severe Traumatic Brain Injury. Journal of the American College of Surgeons. doi:10.1016/j.jamcollsurg.2019.08.677
  More info

  Lokhandwala, Adil MD; Hanna, Kamil MD; Haddadin, Zaid MD; O’Keeffe, Terence MD, FACS; Zeeshan, Muhammad MD; Hamidi, Mohammad K. MD; Joseph, Bellal MD, FACS; Gries, Lynn M. MD, FACS; Ditillo, Michael DO, FACS; Northcutt, Ashley MD Author Information
• Richards, J., Hanna, K., Gries, L., Zeeshan, M., Tang, A., Ditillo, M., Hamidi, M., Northcutt, A., Castañón, L., & Joseph, B. (2019). Prospective Evaluation of Factors Contributing to Racial Disparities in Outcomes after Trauma. Journal of the American College of Surgeons. doi:10.1016/j.jamcollsurg.2019.08.1389
  More info

  Richards, Joseph MS; Hanna, Kamil MD; Gries, Lynn M. MD, FACS; Zeeshan, Muhammad MD; Tang, Andrew L. MD, FACS; Ditillo, Michael DO, FACS; Hamidi, Mohammad K. MD; Northcutt, Ashley MD; Castanon, Lourdes MD; Joseph, Bellal MD, FACS Author Information
• Vartanyan, P., Hanna, K., Zeeshan, M., Hamidi, M., Gries, L., Kulvatunyou, N., Northcutt, A., Castañón, L., Ditillo, M., & Joseph, B. (2019). Chronic Alcoholism Is Bad for Broken Ribs: A Nationwide Analysis of 20,120 Patients with Rib Fractures. Journal of the American College of Surgeons. doi:10.1016/j.jamcollsurg.2019.08.634
  More info

  Vartanyan, Phillip MS; Hanna, Kamil MD; Zeeshan, Muhammad MD; Hamidi, Mohammad K. MD; Gries, Lynn M. MD, FACS; Kulvatunyou, Narong MD; Northcutt, Ashley MD; Castanon, Lourdes MD; Ditillo, Michael DO, FACS; Joseph, Bellal MD, FACS Author Information
• Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. The Surgical clinics of North America, 98(5), 895-913.
  More info

  Acute pancreatitis is an inflammation of the glandular parenchyma of the retroperitoneal organ that leads to injury with or without subsequent destruction of the pancreatic acini. This inflammatory process can either result in a self-limited disease or involve life-threatening multiorgan complications. Chronic pancreatitis consists of endocrine and exocrine gland dysfunction that develops secondary to progressive inflammation and chronic fibrosis of the pancreatic acini with permanent structural damage. Recurrent attacks of acute pancreatitis can result in chronic pancreatitis; acute and chronic pancreatitis are different diseases with separate morphologic patterns. Acute pancreatitis has an increasing incidence but a decreasing mortality.
• Zeeshan, M., Khan, M., O'Keeffe, T., Pollack, N., Hamidi, M., Kulvatunyou, N., Sakran, J. V., Gries, L., & Joseph, B. (2018). Optimal timing of initiation of thromboprophylaxis in spine trauma managed operatively: A nationwide propensity-matched analysis of trauma quality improvement program. The journal of trauma and acute care surgery, 85(2), 387-392.
  More info

  Patients with spinal trauma are at high risk for venous thromboembolic events (VTE). Guidelines recommend prophylactic anticoagulation but they are unclear on timing of initiation of thromboprophylaxis. The aim of our study was to assess the impact of early versus late initiation of venous thromboprophylaxis in patients with spinal trauma who underwent operative intervention.
• Cragun, B., Philp, F. H., Tindall, R. P., O’Neill, J., Bell, N., Noorbakhsh, M. R., Philp, A., & Ditillo, M. (2017). Targeted Temperature Management for Traumatic Arrest. Journal of the American College of Surgeons. doi:10.1016/j.jamcollsurg.2017.07.126
  More info

  Cragun, Benjamin; Philp, Frances Hite; Tindall, Rachel P. MD; O'Neill, John; Bell, Nathan; Noorbakhsh, Matthew MD; Philp, Allan S. MD; Ditillo, Michael F. DO Author Information
• Cragun, B., Philp, F. H., Tindall, R. P., O’Neill, J., Bell, N., Noorbakhsh, M. R., Philp, A., & Ditillo, M. (2016). 352: TARGETED TEMPERATURE MANAGEMENT FOR TRAUMA, SURGICAL, ASPHYXIATION, AND ECMO PATIENTS. Critical Care Medicine SCCM Journals. doi:10.1097/01.ccm.0000509030.65647.91
  More info

  Cragun, Benjamin; Philp, Frances; Tindall, Rachel; O’Neill, John; Bell, Nathan; Noorbakhsh, Matthew; Philp, Allan; Ditillo, Michael
• Galvagno, S. M., Smith, C. E., Varon, A. J., Hasenboehler, E. A., Sultan, S., Shaefer, G., To, K. B., Fox, A. D., Alley, D. E., Ditillo, M., Joseph, B. A., Robinson, B. R., & Haut, E. R. (2016). Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. The journal of trauma and acute care surgery, 81(5), 936-951.
  More info

  Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented.
• Galvagno, S. M., Smith, C. E., Varon, A. J., Hasenboehler, E. A., Sultan, S., Shaefer, G., To, K., Fox, A. D., Alley, D., Ditillo, M., Joseph, B., Robinson, B. R., & Haut, E. R. (2016). Pain management for blunt thoracic trauma. Journal of Trauma and Acute Care Surgery. doi:10.1097/ta.0000000000001209
  More info

  INTRODUCTION Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented. METHODS Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay. RESULTS Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel. CONCLUSION We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.
• Asmar, S., Bible, L., Chehab, M., Tang, A., Khurrum, M., Castanon, L., Ditillo, M., Douglas, M., & Joseph, B. (2021). Traumatic brain injury induced temperature dysregulation: What is the role of β blockers?. The journal of trauma and acute care surgery, 90(1), 177-184.
  More info

  Traumatic brain injury (TBI) is associated with sympathetic discharge that leads to posttraumatic hyperthermia (PTH). Beta blockers (ββ) are known to counteract overactive sympathetic discharge. The aim of our study was to evaluate the effect of ββ on PTH in critically-ill TBI patients.
• Cragun, B. N., Hite Philp, F., O'Neill, J., Noorbakhsh, M. R., Tindall, R. P., Philp, A. S., & Ditillo, M. F. (2018). Therapeutic Hypothermia and Targeted Temperature Management for Traumatic Arrest and Surgical Patients. Therapeutic hypothermia and temperature management, 9(2), 156-158.
  More info

  Therapeutic hypothermia (TH) and targeted temperature management (TTM) have been shown to improve outcomes in survivors of cardiac arrest, but prior research has excluded trauma and postoperative patients. We sought to determine whether TH/TTM is safe in trauma and surgical patients. A retrospective cohort study was conducted at a single level I trauma center reviewing adults presenting as a traumatic arrest or cardiac arrest in the postoperative period with a Glasgow Coma Scale
• Joseph, B., Hadeed, S., Haider, A. A., Ditillo, M., Joseph, A., Pandit, V., Kulvatunyou, N., Tang, A., Latifi, R., & Rhee, P. (2017). Obesity and trauma mortality: Sizing up the risks in motor vehicle crashes. Obesity research & clinical practice, 11(1), 72-78.
  More info

  Protective effects of safety devices in obese motorists in motor vehicle collisions (MVC) remain unclear. Aim of our study is to assess the association between morbid obesity and mortality in MVC, and to determine the efficacy of protective devices. We hypothesised that patients with morbid obesity will be at greater risk of death after MVC.
• Patel, A., Fusi, S., Okanlami, O. O., Ditillo, M., & Sawh-Martinez, R. F. (2015). Blogging to bolster your plastic surgery career. Plastic and reconstructive surgery, 135(3), 658e-659e.
• Patel, A., Fusi, S., Okanlami, O., Ditillo, M., & Sawh-Martinez, R. (2015). Blogging to Bolster Your Plastic Surgery Career. Plastic and Reconstructive Surgery. doi:10.1097/prs.0000000000001109
  More info

  Sir: Social media, including Twitter, Facebook, and Instagram, impact the practice of physicians, including plastic surgeons.1 Patients use social media to gather information and formulate opinions when selecting their plastic surgeon. Plastic surgery residents use social media to share operative articles, collaborate on research initiatives, and discuss politically charged issues affecting the specialty. It should come as no surprise that Plastic and Reconstructive Surgery provides a dedicated social media tab that includes two blog sections: PRSonally Speaking and PRS Resident Chronicles.2,3 Blogging is arguably one of the “older” and most widespread social media tools, and has become an essential component for many plastic surgeons and their associated marketing strategy.4 Despite this, a paucity of information exists in the literature regarding plastic and reconstructive surgery blogs. This article provides tips on creating entertaining, engaging, and educational blogs to assist in the advancement of a plastic surgeon’s career. A blog provides the plastic surgeon a method with which to demonstrate expertise on certain topics or procedures. Generally, these blogs will provide details regarding the clinical and physical features of the surgical problem followed by a description of what the surgery entails. Those that refrain from medical jargon and instead “coach” the potential patient through the surgical procedure tend to be more effective.5 Using evidence-based literature to support claims in blogs adds credibility, which can be further heightened if the author of the blog also wrote the publication. For example, one surgeon uses many of his peer-reviewed articles on rhinoplasty to substantiate his claims, including those on his blog, which gives him credibility and establishes him as one of the premiere experts of this procedure.6–8 A successful blogger must be up-to-date with the innovations of the field to offer patients a comprehensive overview of the procedure being discussed. By using the blog as a proxy for surgical guidance, a plastic surgeon can display expertise and recruit patients to a practice. An important aspect to developing an impactful blog relies on fostering interaction and feedback. The more one can engage the readers, whether they are patients or plastic surgeons, the more likely the blog will produce an interaction that will guide blog entries and keep content relevant. This will allow the plastic surgeon to shape and directly guide patients with many common concerns, and clarify common misconceptions. One way this can occur is by linking one’s blogs to one’s Facebook, Twitter, and Instagram accounts. Tags, handles, and hashtags for Facebook, Twitter, and Instagram, respectively, allow a plastic surgeon to connect with a broader audience. For example, adding the handle of a popular figure along with a picture with the “#aesthetic surgery” when you Twitter about your blog post on a high superficial musculoaponeurotic system rhytidectomy will generalize your specific operation to a wider range of procedures, thereby expanding your outreach. Furthermore, blogs can be interactive by presenting controversial topics and requesting comments from the audience. More interaction will lead to a larger buzz and eventually to a greater number of readers. Blogs can be entertaining to draw readers but must be tempered from “selling” sensationalism, as this can pose a risk to one’s reputation. Negative patient reviews can be magnified by social media’s ubiquitous and instantaneous outreach. Furthermore, one must be cognizant of potential violations of the Health Insurance Portability and Accountability Act.9,10 Plastic surgeons must be overly cautious in their blog statements, making sure to stay attuned and adherent to the ethical boundaries and scope of advertising as advised by the American Society of Plastic Surgeons. Maintaining the highest degree of professionalism will pay dividends in the long run. For busy plastic surgeons, finding time to establish a blog can be a daunting task. In this regard, it is important for all bloggers to engage and work with colleagues. Having guest bloggers, linking to complementary providers, and affiliating with experts in other specialties will serve to add content and guidance that can add tremendous value by pooling resources. Fortunately, Plastic and Reconstructive Surgery will often accept pieces from guest bloggers that are read by the Editor-in-Chief. These pieces include a myriad of topics related to plastic surgery and offer a forum for disseminating ideas. In addition, all blogs on Plastic and Reconstructive Surgery offer a commentary section that affords opportunities to add to the discussion of a blog. Engaging in the world of social media, if executed carefully, often leads to increased Web traffic, which then leads to increased foot traffic—this has been demonstrated in multiple other industries.11 Old and new ventures in all aspects of society have engaged and embraced social media. Any modern organization that engages the public finds it essential to have a social media presence. In medicine, and plastic surgery in particular, the topics of public discussion are extremely personal and sensitive; thus, great caution must be taken to ensure privacy and ethical engagement in such a public manner. When done well, however, the modern plastic surgeon blogger can be a tremendous resource for their community and colleagues and serve to augment any practice. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Anup Patel, M.D., M.B.A. Stefano Fusi, M.D., M.B.A. Oluwaferanmi O. Okanlami, M.D. Michael Ditillo, D.O. Rajendra F. Sawh-Martinez, M.D. Section of Plastic and Reconstructive Surgery Yale University School of Medicine New Haven, Conn.
• Ditillo, M., Joseph, B., Rhee, P., Pandit, V., Castañón, L., Hadeed, S. J., Zangbar, B., Friese, R. S., & Philip, A. (2014). Morbidly obese patients and motor vehicle collisions: are protective devices really protective?. Journal of the American College of Surgeons. doi:10.1016/j.jamcollsurg.2014.07.789
  More info

  Ditillo, Michael F. DO, FACS; Joseph, Bellal MD, FACS; Rhee, Peter M. MD, FACS; Pandit, Viraj MD; Castanon, Lourdes MD; Hadeed, Steven MPH; Zangbar, Bardiya MD; Friese, Randall S. MD, FACS; Philip, Allan MD Author Information
• Ditillo, M., Pandit, V., Rhee, P., Aziz, H., Hadeed, S. J., Bhattacharya, B., Friese, R. S., Davis, K. A., & Joseph, B. (2014). Morbid obesity predisposes trauma patients to worse outcomes. The Journal Trauma and Acute Care Surgery. doi:10.1097/ta.0b013e3182ab0d7c
  More info

  One third of US adults are obese. The impact of obesity on outcomes after blunt traumatic injury has been studied with discrepant results. The aim of our study was to evaluate outcomes in morbidly obese patients after blunt trauma. We hypothesized that morbidly obese patients have adverse outcomes as compared with nonobese patients after blunt traumatic injury.We performed a retrospective analysis of all blunt trauma patients (≥18 years) using the National Trauma Data Bank for years 2007 to 2010. Patients with recorded comorbidity of morbid obesity (body mass index ≥ 40) were identified. Patients transferred, dead on arrival, and with isolated traumatic brain injury were excluded. Propensity score matching was used to match morbidly obese patients to non-morbidly obese patients (body mass index < 40) in a 1:1 ratio based on age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and systolic blood pressure on presentation. The primary outcome was mortality, and the secondary outcome was hospital complications.A total of 32,780 patients (morbidly obese, 16,390; nonobese, 16,390) were included in the study. Morbidly obese patients were more likely to have in-hospital complications (odds ratio [OR], 1.8, 95% confidence interval [CI], 1.6-1.9), longer hospital stay (OR, 1.2; 95% CI, 1.1-1.3), and longer intensive care unit stay (OR, 1.15; 95% CI, 1.09-1.2). The overall mortality rate was 2.8% (n = 851). Mortality was higher in morbidly obese patients compared with the nonobese patients (3.0 vs. 2.2; OR, 1.4; 95% CI, 1.1-1.5).In a cohort of matched patients, morbid obesity is a risk factor for the development of in-hospital complications and mortality after blunt traumatic injury. The results of our study call for attention through focused injury prevention efforts. Future studies are needed to help define the consequences of obesity that influence outcomes.Prognostic study, level III.
• Ditillo, M., Pandit, V., Rhee, P., Aziz, H., Hadeed, S., Bhattacharya, B., Friese, R. S., Davis, K., & Joseph, B. (2014). Morbid obesity predisposes trauma patients to worse outcomes: a National Trauma Data Bank analysis. The journal of trauma and acute care surgery, 76(1), 176-9.
  More info

  One third of US adults are obese. The impact of obesity on outcomes after blunt traumatic injury has been studied with discrepant results. The aim of our study was to evaluate outcomes in morbidly obese patients after blunt trauma. We hypothesized that morbidly obese patients have adverse outcomes as compared with nonobese patients after blunt traumatic injury.
• Joseph, B., Ditillo, M., Pandit, V., Aziz, H., Sadoun, M., Hays, D. P., Davis, K. A., Friese, R. S., & Rhee, P. (2014). Dabigatran Therapy: Minor Trauma Injuries are No Longer Minor. Sage Journals. doi:10.1177/000313481408000407
• Joseph, B., Ditillo, M., Pandit, V., Aziz, H., Sadoun, M., Hays, D., Davis, K., Friese, R., & Rhee, P. (2014). Dabigatran therapy: minor trauma injuries are no longer minor. The American surgeon, 80(4), E116-8.
• Maung, A. A., Schuster, K. M., Kaplan, L. J., Ditillo, M. F., Piper, G. L., Maerz, L. L., Lui, F. Y., Johnson, D. C., & Davis, K. A. (2012). Compared to conventional ventilation, airway pressure release ventilation may increase ventilator days in trauma patients. The journal of trauma and acute care surgery, 73(2), 507-10.
  More info

  Airway pressure release ventilation (APRV) is used both as a rescue therapy for patients with acute lung injury and as a primary mode of ventilation. Unlike assist-control volume (ACV) ventilation that uses spontaneous breathing trials, APRV weaning consists of gradual decreases in supporting pressure. We hypothesized that the APRV weaning process increases total ventilator days compared with those of spontaneous breathing trials-based weaning.
• Sixta, S., Moore, F. O., Ditillo, M. F., Fox, A. D., Garcia, A. J., Holena, D., Joseph, B., Tyrie, L., & Cotton, B. (2012). Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery of Trauma practice management guideline. The journal of trauma and acute care surgery, 73(5 Suppl 4), S326-32.
  More info

  Thoracolumbar spine (TLS) injuries have an incidence rate of 5% in blunt trauma patients. The Eastern Association for the Surgery of Trauma published Practice Management Guidelines for the Screening of Thoracolumbar Spine Fracture in 2007. The Practice Management Guidelines Committee was assembled to reevaluate the literature.
• Sixta, S., Moore, F. O., Ditillo, M., Fox, A. D., Garcia, A. J., Holena, D. N., Joseph, B., Tyrie, L., & Cotton, B. A. (2012). Screening for thoracolumbar spinal injuries in blunt trauma. The Journal of Trauma and Acute Care Surgery. doi:10.1097/ta.0b013e31827559b8
  More info

  In Brief BACKGROUND Thoracolumbar spine (TLS) injuries have an incidence rate of 5% in blunt trauma patients. The Eastern Association for the Surgery of Trauma published Practice Management Guidelines for the Screening of Thoracolumbar Spine Fracture in 2007. The Practice Management Guidelines Committee was assembled to reevaluate the literature. METHODS A search of the United States National Library of Medicine and the National Institutes of Health database was performed using MEDLINE through PubMed (www.pubmed.gov). The search retrieved English-language articles from March 2005 to December 2011 that referenced traumatic TLS injuries and fractures. The questions posed were the following: (1) What is the appropriate imaging modality to screen patients for TLS injuries? (2) Which trauma patients require radiographic screening for TLS injuries? (3)Does a patient who is awake and alert without distracting injuries require radiologic workup to rule out TLS injuries? RESULTS Thirty-seven articles that referenced traumatic TLS injuries in association with screening published between March 2005 and December 2011 were collected and disseminated to the committee. Twelve were found to be relevant. Nine publications from the previous 2006 guidelines were reviewed and referenced to create and validate the updated guidelines. CONCLUSION Practice patterns have changed regarding screening blunt trauma patients for TLS injuries. Software reformatted multidetector computed tomographic scans are more sensitive and accurate than plain films. Multidetector computed tomographic scans have become the screening modality of choice and the criterion standard in screening for TLS injuries. The literature supports a Level 1 recommendation to validate this based on a preponderance of Class II data. Patients without altered mentation or significant mechanism may be excluded by clinical examination without imaging. Patients with gross neurologic deficits or concerning clinical examination findings with negative imaging should receive a magnetic resonance imaging expediently, and the spine service should be consulted. Supplemental digital content is available in the article.
• O'Connor, J., Ditillo, M., & Scalea, T. (2009). Penetrating cardiac injury. Journal of the Royal Army Medical Corps, 155(3), 185-90.
  More info

  It is understood that penetrating cardiac trauma is a highly lethal injury and those surviving to hospital have an overall mortality approaching 80%. Reported mortality figures vary widely and are extremely dependent on mechanism of wounding, cardiac chambers involved and possibly the presence of cardiac tamponade. Despite significant advances in prehospital care, operative techniques, and intensive care management, the mortality has not changed over several decades. This article will review the anatomic regions of concern for a cardiac injury, clinical presentation, and physical findings. The need for an expeditious evaluation and modalities available including, plain radiographs, sub-xiphoid window, and echocardiography will be considered. Options for surgical exposure, technical details of repairing cardiac injuries, and special circumstances such as injury adjacent to a coronary artery and intra-cardiac shunts are discussed in detail. Outcome data and future directions in managing this challenging injury are also examined.
• O’Connor, J. V., Ditillo, M., & Scalea, T. M. (2009). Penetrating Cardiac Injury. BMJ Journal. doi:10.1136/jramc-155-03-02
  More info

  It is understood that penetrating cardiac trauma is a highly lethal injury and those surviving to hospital have an overall mortality approaching 80%. Reported mortality figures vary widely and are extremely dependent on mechanism of wounding, cardiac chambers involved and possibly the presence of cardiac tamponade. Despite significant advances in prehospital care, operative techniques, and intensive care management, the mortality has not changed over several decades. This article will review the anatomic regions of concern for a cardiac injury, clinical presentation, and physical findings. The need for an expeditious evaluation and modalities available including, plain radiographs, sub-xiphoid window, and echocardiography will be considered. Options for surgical exposure, technical details of repairing cardiac injuries, and special circumstances such as injury adjacent to a coronary artery and intra-cardiac shunts are discussed in detail. Outcome data and future directions in managing this challenging injury are also examined.
• Ditillo, M. F., Dziura, J. D., & Rabinovici, R. (2006). Is it safe to delay appendectomy in adults with acute appendicitis?. Annals of surgery, 244(5), 656-60.
  More info

  To examine whether delayed surgical intervention in adult patients with acute appendicitis is safe by correlating the interval from onset of symptoms to operation (total interval) with the degree of pathology and incidence of postoperative complications.
• Ditillo, M., Dziura, J., & Rabinovici, R. (2006). Is It Safe to Delay Appendectomy in Adults With Acute Appendicitis?. Annals of Surgery. doi:10.1097/01.sla.0000231726.53487.dd
  More info

  To examine whether delayed surgical intervention in adult patients with acute appendicitis is safe by correlating the interval from onset of symptoms to operation (total interval) with the degree of pathology and incidence of postoperative complications.Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to advanced pathology. This time-honored practice has been recently challenged by studies in pediatric patients, which suggested that acute appendicitis can be managed in an elective manner once antibiotic therapy is initiated. No such data are available in adult patients with acute appendicitis.A retrospective review of 1081 patients who underwent an appendectomy for acute appendicitis between 1998 and 2004 was conducted. The following parameters were monitored and correlated: demographics, time from onset of symptoms to arrival at the emergency room (patient interval) and from arrival to the emergency room to the operating room (hospital interval), physical, computed tomography (CT scan) and pathologic findings, complications, length of stay, and length of antibiotic treatment. Pathologic state was graded 1 (G1) for acute appendicitis, 2 (G2) for gangrenous acute appendicitis, 3 (G3) for perforation or phlegmon, and 4 (G4) for a periappendicular abscess.The risk of advanced pathology, defined as a higher pathology grade, increased with the total interval. When this interval was 71 hours group compared with total interval
• Busidan, Y., Shaffer, L., Ditillo, M., & Dow-Edwards, D. (1997). Perinatal AZT (Zidovudine): neurobehavioral effects in a rat model. Neurotoxicology and Teratology. doi:10.1016/s0892-0362(97)82432-4

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 The Journal of Trauma and Acute Care Surgery.
  More info

  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 (
• Bhogadi, S., Colosimo, C., Hosseinpour, H., Nelson, A., Rose, M., Calvillo, A., Anand, T., Ditillo, M., Magnotti, L., & Joseph, B. (2023). The undisclosed disclosures: The dollar-outcome relationship in resuscitative endovascular balloon occlusion of the aorta. In The Journal of Trauma and Acute Care Surgery.
  More info

  BACKGROUND Despite its rapid evolution, resuscitative endovascular balloon occlusion of the aorta (REBOA) remains a controversial intervention that continues to generate active research. Proper conflict of interest (COI) disclosure helps to ensure that research is conducted objectively, without bias. We aimed to identify the accuracy of COI disclosures in REBOA research. METHODS Literature search was performed using the keyword "REBOA"on PubMed. Studies on REBOA with at least one American author published between 2017 and 2022 were identified. The Centers for Medicare and Medicaid Services Open Payments database was used to extract information regarding payments to the authors from the industry. This was compared with the COI section reported in the manuscripts. Conflict of interest disclosure was defined as inaccurate if the authors failed to disclose any amount of money received from the industry. Descriptive statistics were performed. RESULTS We reviewed a total of 524 articles, of which 288 articles met the inclusion criteria. At least one author received payments in 57% (165) of the articles. Overall, 59 authors had a history of payment from the industry. Conflict of interest disclosure was inaccurate in 88% (145) of the articles where the authors received payment. CONCLUSION Conflict of interest reports are highly inaccurate in REBOA studies. There needs to be standardization of reporting of conflicts of interest to avoid potential bias. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
• Tang, A., Chehab, M., Ditillo, M., Asmar, S., Khurrum, M., Douglas, M., Bible, L., Kulvatunyou, N., & Joseph, B. (2021). Regionalization of trauma care by operative experience: Does the volume of emergent laparotomy matter?. In The Journal of Trauma and Acute Care Surgery.
  More info

  INTRODUCTION The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients. METHODS We performed a (2017) analysis of the Trauma Quality Improvement Program database. We included adult (age, =18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: High volume (HV), =25 cases per year; medium volume (MV), 13 to 24 cases per year; and low volume (LV), =12 cases per year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality. RESULTS A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean ± SD age was 40 ± 17 years, abdomen Abbreviated Injury Scale was 3 (2-4), and Injury Severity Score was 26 (17-35). For American College of Surgeons (ACS) level I centers, 50% were HV; 29%, MV; and 21%, LV. For ACS level II centers, 7% were HV; 23%, MV; and 70%, LV. For ACS level III centers, 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. High-volume blunt centers had a significantly lower time to laparotomy (72 [41-144] minutes) versus MV (81 [49-145] minutes) and LV (94 [56-158] minutes) centers (p < 0.001). The same trend was observed for HV penetrating trauma centers (35 [24-52] minutes) versus MV (46 [33-63] minutes) and LV (51 [38-69] minutes) centers (p < 0.001). CONCLUSION Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers' injury-specific operative experience. LEVEL OF EVIDENCE Prognostic, Level III; Therapeutic/Care management, Level IV.
• Castanon, L., Asmar, S., Bible, L., Chehab, M., Ditillo, M., Khurrum, M., Hanna, K., Douglas, M., & Joseph, B. (2020). Early enteral nutrition in geriatric burn patients: Is there a benefit?. In Journal of Burn Care & Research.
  More info

  Nutrition is a critical component of acute burn care and wound healing. There is no consensus over the appropriate timing of initiating enteral nutrition in geriatric burn patients. This study aimed to assess the impact of early enteral nutrition on outcomes in this patient population. We performed a 1-year (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program and included all older adult (age ≥65 years) isolated thermal burn patients who were admitted for more than 24 hr and received enteral nutrition. Patients were stratified into two groups based on the timing of initiation of feeding: early (≤24 hr) vs late (>24 hr). Multivariate logistic regression was performed to control for potential confounding factors. Outcome measures were hospital and intensive care unit lengths of stay, in-hospital complications, and mortality. A total of 1,004,440 trauma patients were analyzed, of which 324 patients were included (early: 90 vs late: 234). The mean age was 73.9 years and mean TBSA burnt was 31%. Patients in the early enteral nutrition group had significantly lower rates of in-hospital complications and mortality (15.6% vs 26.1%; P = 0.044), and a shorter hospital length of stay (17 [11,23] days vs 20 [14,24] days; P = 0.042) and intensive care unit length of stay (13 [8,15] days vs 17 [9,21] days; P = 0.042). In our regression model of geriatric burn patients, early enteral nutrition was associated with improved outcomes. The cumulative benefits observed may warrant incorporating early enteral nutrition as part of intensive care protocols.

Presentations

• Meka, J., Ditillo, M., Horak, H. A., & Corral, J. (2021, April). Workplace-Based Assessment in Clinical Education: An Adoption Cycle of Experience. AAMC GEA 2021. Virtual: AAMC.
• Ditillo, M. (2018, January). Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Finding. Academic Surgical Congress. Jacksonville, FL.
• Ditillo, M. (2018, October). Desmopressin Reverses Platelet Inhibition In The ADP Pathway In Patients With Blunt Traumatic Brain Injuries. SABM Annual Meeting. Brooklyn, NY.
• Ditillo, M. (2017, August). Therapeutic Hypothermia: TO Chill or Not to Chill. PASCCM 22st Annual Challenges in Critical Care. Hershey, PA.
• Ditillo, M. (2017, December). Hemorrhage Control: From the Field to the ICU. Armstrong EMS Conference. Armstrong, PA.
• Ditillo, M. (2017, January). Targeted Temperature Management for Trauma and Surgical Patients. SCCM 46th Critical Care Congress. Honolulu, HI.
• Ditillo, M. (2017, July). Treatment of Blunt Thoracic Trauma. Allegheny General Hospital Nursing Trauma Symposium. Pittsburgh, PA.
• Ditillo, M. (2017, Ocotber). Targeted Temperature Management for Traumatic Arrest. American College of Surgeons Clinical Congress 2017. San Diego, CA.
• Ditillo, M. (2017, September). Damage Control Resuscitation. 65th AOCA Annual Convention. Miami Beach, FL.
• Ditillo, M. (2016, August). Damage Control Resuscitation: Blood is Thicker than Water. PASCCM 21st Annual Challenges in Critical Care. Hershey, PA.
• Ditillo, M. (2016, February). Adjuncts to Hemostasis. Grove City EMS Conference. Grove City, PA.
• Ditillo, M. (2016, July). Approach To Mass Casualty Event: The Hartford Consensus and Beyond. Allegheny General Hospital Nursing Trauma Symposium. Pittsburgh, PA.
• Ditillo, M. (2016, June). Damage Control Resucitation: Blood is Thicker Than Water. Audio-Digest Anesthesiology Volume 58, Issue 23.
• Ditillo, M. (2016, March). Damage Control Resuscitation: Blood is Thicker Than Water. Seventh Annual Allegheny Health System Anesthesia Update, New Approaches to Familiar Topics. Pittsburgh, PA.
• Ditillo, M. (2016, March). The Geriatric Trauma Patient. Pennsylvania EMS Update 2016. Pittsburgh, PA.
• Ditillo, M. (2016, October). Functional Recovery in Elderly after Trauma: The Impact of Frailty. American College of Surgeons Clinical Congress 2016. Washington, DC.
• Ditillo, M. (2015, July). Critical Care Alphabet Soup: Implementation of the ABCDEF Bundle in the ICU. Allegheny General Hospital Nursing Trauma Symposium. Pittsburgh, PA.
• Ditillo, M. (2015, July). The Mangled Extremity, An Evidence Based Approach. Allegheny General Hospital Nursing Trauma Symposium. Pittsburgh, PA.
• Ditillo, M. (2015, June). Damage Control Resucitation an Evidence Based Approach. Allegheny Health Network Anesthesia Grand Rounds. Pittsburgh, PA.
• Ditillo, M. (2015, March). All Bleeding Stops…One Way or Another. Pennsylvania EMS Update 2015. Pittsburgh, PA.
• Ditillo, M. (2015, November). Hemorrhage Control: From the Field to the ICU. Clarion EMS Conference. Clarion, PA.
• Ditillo, M. (2015, September). “Down But Not Out: Rib Fractures In The Super-Elderly. 74th Annual Meeting of the AAST and Clinical Congress of Acute Care Surgery. Las Vegas, NV.
• Ditillo, M. (2014, October). Morbidly Obese Patients and Motor Vehicle Collisions: Are Protective Devices Really Protective?. American College of Surgeons Clinical Congress 2014. San Francisco, CA.
• Ditillo, M. (2014, September). Fraility and Surgery. Allegheny General Hospital General Surgery Grand Rounds. Pittsburgh, PA.
• Ditillo, M. (2013, April). Approach to the Geriatric Trauma Patient. 15th Annual Connecticut Trauma Conference. Ledyard, CT.
• Ditillo, M. (2013, January). Pain Management in Blunt Thoracic Trauma. 26th Annual Meeting of the Eastern Association for the Surgery of Trauma. Scottsdale, AZ.
• Ditillo, M. (2013, October). Obesity Predisposes Trauma Patients to Worse Outcomes: A National Trauma Data Bank Analysis. American College of Surgeons Clinical Congress 2013. Washington, DC.
• Ditillo, M. (2013, September). Obesity Predisposes Trauma Patients to Worse Outcomes: A National Trauma Data Bank Analysis. 72nd Annual Meeting of the AAST and Clinical Congress of Acute Care Surgery. San Francisco.
• Ditillo, M. (2012, April). Does a Liberalized Fluid Protocol Improve Tissue Perfusion in Lung Resection Surgery without increasing Lung Water?. Association of VA Surgeons Annual Meeting. Miami, FL.
• Ditillo, M. (2012, February). Therapeutic Hypothermia: Past Present and Future. Surgical Grand Rounds. Brookdale University Hospital and Medical Center Brooklyn, NY.
• Ditillo, M. (2012, January). Practice Management Guidelines for the Screening of Thoracolumbar Spinal Injury in Blunt Trauma Eastern Association for the Surgery of Trauma Practice Management Guideline Committee. 25th Annual Meeting of the Eastern Association for the Surgery of Trauma. Naples, FL.
• Ditillo, M. (2012, March). The Mangled Extremity, An Evidence Based Approach. Yale School of Medicine Plastic Surgery Grand Rounds. New Haven, CT.
• Ditillo, M. (2012, May). Liberalized Fluid Protocol and Tissue Perfusion Biomarkers in Lung Resection Surgery. International Anesthesia Research Society. Boston, MA.
• Ditillo, M. (2012, May). “Does A Liberalized Fluid Protocol Increase Lung Water Post Lung Resection Surgery?. International Anesthesia Research Society. Boston, MA.
• Ditillo, M. (2011, January). Brief episodes of intracranial hypertension and cerebral hypoperfusion are associated with poor functional outcomes following severe traumatic brain injury. 24th Annual Meeting of the Eastern Association for the Surgery of Trauma. Naples, FL.
• Ditillo, M. (2011, June). Damage Control Resucitation: Blood is Thicker Than Water. Surgical Grand Rounds. St. Mary’s Medical Center Waterbury, CT.
• Ditillo, M. (2010, April). To Chill or Not to Chill-Therapeutic Hypothermia After Cardiac Arrest. Yale School of Medicine Surgical Grand Rounds. New Haven, CT.
• Ditillo, M. (2010, January). Therapeutic Hypothermia Post Cardiac Arrest: An Evidence Based Approach. Surgical Grand Rounds. Bridgeport Hospital-Yale New Haven Health System Bridgeport, CT.
• Ditillo, M. (2010, November). When the ICU is the OR. Connecticut Chapter of the American College of Surgeons Professional Association. Waterbury, CT.
• Ditillo, M. (2010, September). Outcomes of alcohol use in elderly trauma patients. 69th Annual Meeting of the American Association for the Surgery of Trauma. Boston, Massachusetts.
• Ditillo, M. (2009, October). Outcomes of alcohol use in elderly trauma patients. Connecticut Chapter of the American College of Surgeons Professional Association. Waterbury, CT.

Poster Presentations

• Ditillo, M. (2021). Does Thromboelastography Predict Preinjury Anticoagulation In Traumatic Brain Injury?. American Association for the Surgery of Trauma 80th Annual and Clinical Congress.
• Ditillo, M. (2018). Desmopressin Reverses Platelet Inhibition In The ADP Pathway In Patients With Blunt Traumatic Brain Injuries. SABM Annual Meeting.
• Ditillo, M. (2017, September). Targeted Temperature Management for Trauma Arrest. American Association for the Surgery of Trauma 76th Annual and Clinical Congress. Baltimore, MD.
• Ditillo, M. (2010). Outcomes of alcohol use in elderly trauma patients. 69th Annual Meeting of the American Association for the Surgery of Trauma.
• Ditillo, M. (2007, April). Not Just a Routine Hernia Operation. American Hernia Society.
• Ditillo, M. (2007, November). Cocaine: Effects on Developing Brains.” Poster Presentation. New York Academy Of Sciences. New York.
• Ditillo, M. (1997, October). Perinatal AZT (Zidovudine): neurobehavioral effects in a rat model. Neurobehavior and Teratology.

Reviews

• Bhogadi, S. K., Colosimo, C., Hosseinpour, H., Nelson, A., Rose, M. I., Calvillo, A. R., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023. The undisclosed disclosures: The dollar-outcome relationship in resuscitative endovascular balloon occlusion of the aorta(pp 726-730).
  More info

  Despite its rapid evolution, resuscitative endovascular balloon occlusion of the aorta (REBOA) remains a controversial intervention that continues to generate active research. Proper conflict of interest (COI) disclosure helps to ensure that research is conducted objectively, without bias. We aimed to identify the accuracy of COI disclosures in REBOA research.