Tanya Anand

Interests

Research

Endotheliopathy of TraumaGeriatric TraumaHemorrhagic Shock and Resuscitation

Courses

Scholarly Contributions

Books

• Kacprzyk, J., Pal, N., Pérez, R., Corchado, E., Hagras, H., Kóczy, L. T., Kreinovich, V., Lin, C., Lu, J., Melín, P., Nedjah, N., Nguyên, N. T., Wang, J., Wang, J., Prasad, V. K., Reddy, K. H., Reddy, S., Reddy, C. B., Reddy, V. B., , Chandra, S., et al. (2022). Soft Computing and Signal Processing. doi:10.1007/978-981-16-1249-7

Chapters

• Anand, T., Asmar, S., & Joseph, B. (2021). Is it Time for REBOA to be Considered as an Equivalent to Resuscitative Thoracotomy?. In Is it Time for REBOA to be Considered as an Equivalent to Resuscitative Thoracotomy?. doi:10.1007/978-3-030-81667-4_5
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  In severe non-compressible torso hemorrhage (NCTH), proximal aortic control is needed for survival in many cases. The benchmark to obtain this control is typically achieved by emergency surgery coupled with a resuscitative thoracotomy (RT). Recently, a non-invasive method, resuscitative endovascular balloon occlusion of the aorta (REBOA), has become a feasible consideration for hemorrhage control. REBOA has emerged as an attractive tool when combined with whole blood resuscitation to temporize hemorrhage and extend the “golden hour.” However, REBOA’s ability to replace RT remains limited. Indications for RT vs. REBOA are primarily based on the patient’s injury pattern and physiological status at the presentation in the trauma bay. The current indications for REBOA remain speculative and are based on expert opinion with no complete consensus, while RT has stood the test of time. In its current state and indications, it is not time for REBOA to replace RT in patients with severe NCTH. However, there might be a future for REBOA, but it is with a specific patient population and a specific set of indications that will allow this procedure to succeed. Increased efforts should focus on integrating REBOA to RT instead of attempting to replace it.
• Anand, T. (2020). Is it time for REBOA to replace emergent resuscitative thoracotomies?. In Difficult Decisions in Trauma Surgery.

Journals/Publications

• Al Ma'ani, M., Hejazi, O., Sarani, B., Castillo Diaz, F., Khurshid, M. H., Nelson, A., Stewart, C., Anand, T., Magnotti, L. J., & Joseph, B. (2026). Outcomes of rib fixation versus nonoperative management in flail chest: Does body mass index change the equation?. The journal of trauma and acute care surgery, 100(1), 47-53.
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  The aim of this study is to identify the relationship between body mass index (BMI) and outcomes of surgical stabilization of rib fractures (SSRF) versus nonoperative management.
• Al Ma'ani, M., Castillo Diaz, F., Khurshid, M. H., Hejazi, O., Anand, T., Spencer, A. L., Stewart, C., Kunac, A., Magnotti, L. J., & Joseph, B. (2025). Silence of the Brittle: The Role of Frailty in Pain Perception and Management in Geriatric Trauma Patients. Journal of Surgical Research, 314(Issue). doi:10.1016/j.jss.2025.06.079
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  Introduction: Pain management in geriatric trauma patients is linked to improved quality of life and better outcomes. However, the role of patient-related factors in pain perception and management is unknown. The aim of our study is to assess whether frailty is associated with differences in daily pain scores and analgesic use among geriatric trauma patients. Methods: We performed a 2-y (2021-2022) analysis of geriatric database at our level I trauma center. We included all geriatric (≥65 y) patients admitted to our trauma service with normal neurological exam and length of stay >48 h. Patients were stratified using the trauma-specific frailty index into frail (F) and nonfrail (NF) groups. Daily pain scores (10-point numeric scale), the highest reported pain score during the admission, regional and systemic analgesia received in the first 7 d, and overall analgesic requirements were recorded and compared. Analgesics were converted to morphine milligram equivalents. Descriptive statistics and multivariable linear regression analyses, adjusting for potential confounding factors were performed. Results: We identified a total of 275 geriatric trauma patients (NF 167, F 108). The mean age was 78 (8) y and 52% were male. The median injury severity score was 9 [4-10], with 93% sustaining blunt injuries. There were no significant differences in terms of patients’ demographic and injury characteristics between F and NF groups. On univariate analysis, the F group were less likely to report pain and had significantly lower opioid morphine milligram equivalent requirements in the first week of admission and overall. On linear regression analysis, frailty was independently associated with lower average pain scores in the first week (β = −1.81, 95% confidence interval [CI] [−3.51 to −0.11], P = 0.038), lower overall highest pain scores (β = −0.97, 95% CI [−1.64 to −0.302], P = 0.05), and received less opioids per day in the first week (β = −10.63, 95% CI [−16.55 to −4.71], P < 0.001) and overall (β = −15.02, 95% CI [−22.81 to −7.24], P < 0.001). Subanalysis of patients substratified by injury severity score showed similar trends. Conclusions: Frailty was associated with lower reported pain scores and reduced opioid use, regardless of injury severity. Whether these discrepancies are owing to differences in pain perception by patients or under-reporting it to health-care providers is yet to be understood. These findings lay the foundation for further research to explore the role of frailty on the pathophysiology of pain in geriatric trauma patients.
• Al Ma'ani, M., Castillo Diaz, F., Khurshid, M. H., Hejazi, O., Anand, T., Spencer, A. L., Stewart, C., Kunac, A., Magnotti, L. J., & Joseph, B. (2025). Silence of the Brittle: The Role of Frailty in Pain Perception and Management in Geriatric Trauma Patients. The Journal of surgical research, 314, 291-297.
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  Pain management in geriatric trauma patients is linked to improved quality of life and better outcomes. However, the role of patient-related factors in pain perception and management is unknown. The aim of our study is to assess whether frailty is associated with differences in daily pain scores and analgesic use among geriatric trauma patients.
• Anand, T., Hejazi, O., Nelson, A., Litmanovich, B., Spencer, A. L., Khurshid, M. H., Ghaedi, A., Hosseinpour, H., Magnotti, L. J., & Joseph, B. (2025). Early Vasopressor Requirement Among Hypotensive Trauma Patients: Does It Cause More Harm Than Good?. The American surgeon, 91(Issue 1). doi:10.1177/00031348241269425
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  BACKGROUND: Optimal utilization of vasopressors during early post-injury resuscitation remains unclear. Our study aims to describe the relationship between the timing of vasopressor administration and outcomes among hypotensive trauma patients. METHODS: This was a retrospective analysis of the 2017-2018 ACS-TQIP database. We included adult (≥18 years) trauma patients presenting with hypotension (lowest SBP 3) and those with spinal cord injury (Spine-AIS >3). Patients were stratified based on the time to receive vasopressors. Multivariable regression analyses were performed to identify the independent association between timing of vasopressor initiation and outcomes. RESULTS: 1049 patients were identified. Mean age was 55 ± 20 years, and 70% of patients were male. The median ISS was 16 [9-24], 80% had a blunt injury, and the mean SBP was 61 ± 24 mmHg. The median time to first vasopressor administration was 319 [68-352] minutes. Overall, 24-hour and in-hospital mortality rates were 19% and 33%, respectively. Every one-hour delay in vasopressor administration beyond the first hour was independently associated with decreased odds of 24-hour mortality (aOR: 0.65, P < 0.001), in-hospital mortality (aOR: 0.65, P < 0.001), major complications (aOR: 0.77, P = 0.003), and increased odds of longer ICU LOS (β + 2.53, P = 0.012). There were no associations between the timing of early vasopressor administration and 24-hour PRBC transfusion requirements (P > 0.05). CONCLUSION: Earlier vasopressor requirement among hypotensive trauma patients was independently associated with increased mortality and major complications. Further research on the utility and optimal timing of vasopressors during the post-injury resuscitative period is warranted. LEVEL OF EVIDENCE: III therapeutic/care management.
• Anand, T., Hosseinpour, H., Ditillo, M., Bhogadi, S. K., Akl, M. N., Collins, W. J., Magnotti, L. J., & Joseph, B. (2025). The Importance of Circulation in Airway Management: Preventing Postintubation Hypotension in the Trauma Bay. Annals of Surgery, 281(Issue 1). doi:10.1097/sla.0000000000006288
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  Objective: To identify the modifiable and nonmodifiable risk factors associated with postintubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay. Background: ETI has been associated with hemodynamic instability, termed PIH, yet its risk factors in trauma patients remain underinvestigated. Methods: This is a prospective observational study at a level I trauma center over 4 years (2019-2022). All adult (≥18) trauma patients requiring ETI in the trauma bay were included. Blood pressure was monitored both preintubation and postintubation. Multivariable logistic regression analysis was performed to identify the modifiable and nonmodifiable factors associated with PIH. Results: Seven hundred eight patients required ETI in the trauma bay, of which, 435 (61.4%) developed PIH. The mean (SD) age was 43 (21) years and 71% were male. Median [interquartile range] arrival Glasgow Coma Scale was 7 [3-13]. Patients who developed PIH had a lower mean (SD) preintubation systolic blood pressure [118 (46) vs 138 (28), P
• Anand, T., McLoud, S., Loss, L., Minoza, K., Jenkins, P., Rowell, S., McLean, J., Joseph, B., & Schreiber, M. (2025). Age matters: A Secondary Analysis of Endothelial Biomarkers in the Prehospital Tranexamic Acid for Traumatic Brain Injury Trial. Journal of Trauma and Acute Care Surgery. doi:10.1097/ta.0000000000004582
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  BACKGROUND Injured older adults account for nearly 25% of trauma admissions nationwide with increased morbidity and mortality compared with younger adults. Endothelial dysfunction has been associated with poor outcomes in trauma patients. We hypothesized that posttraumatic endothelial changes in older versus younger adult trauma patients will be different with worse outcomes in older adults. METHODS This is a retrospective secondary analysis of the "Tranexamic Acid (TXA) in Traumatic Brain Injury"prehospital database (2015-2017). We studied patients with admission endothelial biomarkers: intercellular adhesion molecule 1, angiotensin 1, thrombomodulin, vascular cell adhesion molecule 1 (VCAM 1), angiotensin 2, syndecan-1, and thrombospondin. We divided patients into age quartiles and compared the oldest quartile (older age [OA] group) with the three youngest quartiles (younger age [YA] group). In-hospital, discharge, and mortality outcomes were compared. Significance was set at p < 0.05. RESULTS A total of 436 patients were included. The mean age in OA group was 66 years (55-88 years, n = 108). The YA mean age was 30 years (15-54 years, n = 328). There was no difference between OA and YA in rates of blunt trauma (98.1% vs. 96.3%, p = 0.61), head abbreviated injury scale (mean, 2.83 vs. 2.93; p = 0.582), or Injury Severity Score (mean, 21 vs. 19; p = 0.29). Tranexamic acid dosing was not different between cohorts (p = 0.571). Overall, the OA group had higher thrombomodulin (median, 693.3 vs. 592.9 pg/mL; p = 0.0008), VCAM 1 (median, 70,852 vs. 59,738 pg/mL; p = 0.0015), and angiotensin 2 (median, 165.3 vs. 134.2 pg/mL; p = 0.005). When comparing endothelial biomarkers of OA to each YA age quartile subsets, in the 2g TXA group OA patients had significantly higher syndecan-1 levels from a subset of YA (37 to 54-year-olds, p = 0.034). In the 2g TXA group OA patients had significantly lower plasma thrombomodulin, angiotensin 2, and VCAM 1 (p = 0.00001, p = 0.0032, and p = 0.0002, respectively) than patients in the placebo group. None of the biomarkers were independent predictors of 28-day mortality. CONCLUSION Despite similar injury patterns, OA presented with higher admission endothelial plasma biomarkers. The OA patients receiving 2 g of TXA had significantly different endothelial biomarker levels versus YA group. These differences suggest that OA patients have a different baseline endothelial function prior to injury and that TXA may have a more pronounced effect on injured OA versus YA endothelium. LEVEL OF EVIDENCE Therapeutic Care Management; Level IV.
• Brugere, E., Preston, J., Durazo, F., Rajakaruna, S., Tfaily, M., Joseph, B., Benjamin, E., & Anand, T. (2025). The Potential of Precision: A Scoping Review of Patient Metabolic Patterns After Traumatic Brain Injury. Journal of Surgical Research, 313(Issue). doi:10.1016/j.jss.2025.06.033
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  Introduction: Despite the injury burden, categorization and prognostication of traumatic brain injury (TBI) severity is primarily based on a combination of clinical examination, imaging, and certain adjuncts such as electroencephalogram and intracranial pressure monitors. Understanding metabolite patterns after TBI may serve as a more precise method to describe and prognosticate injury severity, guide treatment, and serve as a valuable adjunct to current diagnostic and treatment modalities. In this review, we aim to consolidate current metabolomics research on patients sustaining a TBI, describing how metabolite changes are associated with TBI severity, treatment, and outcomes, with a specific focus on studies of clinically accessible samples (blood and/or urine). Materials and methods: We performed a scoping review of the literature and screened articles using Covidence software. Articles detailing post-TBI metabolites in patient blood and/or urine samples were included, while studies describing data solely from cerebrospinal fluid samples, pediatric populations, or animal studies were excluded. Results: We included 28 articles from our initial search yield of 771. Commonly increased metabolites in the acute phase included decanoic acid, lysophosphatidylcholine (LPC), 2-hydroxybutyrate (all increased in moderate to severe TBI), certain amino acids, and various LPCs (decreased in moderate to severe TBI). After 48 h, octanoic acid, decanoic acid, and LPC increased while glucose, pyruvate, and N-acetylaspartate decreased. LPC and methionine were associated with improved prognosis, while glutamate and octanoic acid were associated with worse prognosis. Conclusions: Based on our review, amino acids generally decline with greater injury severity, while lipids increase early in severe TBI patients. Choline phospholipids are strong predictors of TBI patient outcomes. Early metabolically targeted TBI therapies may result in improved outcomes in moderate to severely injured patients. Further research is warranted to examine if metabolite biomarkers can serve as prognostication tools or guides for therapy.
• Castillo Diaz, F., Anand, T., Khurshid, M. H., Kunac, A., Al Ma'Ani, M., Colosimo, C., Hejazi, O., Ditillo, M., Magnotti, L. J., & Joseph, B. (2025). Look me in the face and tell me that i needed to be transferred: Defining the criteria for transferring patients with isolated facial injuries. Journal of Trauma and Acute Care Surgery. doi:10.1097/ta.0000000000004651
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  OBJECTIVES Despite the known burden of inappropriate overtriage of patients with facial injuries on the health care system, no comprehensive guidelines for the transfer of these patients exist. The aim of this study was to define guidelines regarding which patients with isolated craniomaxillofacial trauma require transfer to higher levels of care. METHODS We performed a 5-year review at a Level I trauma center (2017-2021). We included all transferred patients with isolated facial fractures. Patients were stratified into appropriate (those who received any emergency [taken directly to operating room] or urgent intervention [intervention in same admission] for facial injuries or were admitted to the ward for observation) and potentially inappropriate (patients who did not require any emergent or urgent intervention or admission to the facial trauma service [FTS]) transfers. Three independent experts reviewed the reason for the transfer and required interventions during the hospitalization and defined if the transfer was appropriate. RESULTS We identified 511 patients transferred to our Level I trauma center with isolated facial injuries. Over half (n = 259, 51%) of these transfers were potentially unnecessary, as these patients did not require intervention or admission. Overall, FTS was consulted for 89% of patients. A total of 252 patients (49%) were identified as appropriate transfers, of which 54% were admitted to the floor, 15% received emergency intervention, and 79% underwent urgent intervention. Eighty-two percent of potentially inappropriate transfers received an FTS consultation, and 81% were discharged from ED with a median length of stay of 6 hours. After a review of patient's hospitalization events, the Facial Injury Guidelines were defined. CONCLUSION More than half of the patients with isolated facial fractures did not require any intervention or admission. The proposed guidelines could significantly reduce unnecessary transfers and health care costs for patients with isolated craniomaxillofacial trauma. Prospective validation of the Facial Injury Guidelines is warranted before it could be considered for implementation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
• Colosimo, C., Mahankali, P., Hejazi, O., Bhogadi, S., Anand, T., Nelson, A., Stewart, C., Spencer, A., Ditillo, M., Magnotti, L., & Joseph, B. (2025). On the backseat: Analyzing motorcycle passenger injuries in children. American Journal of Surgery, 247(Issue). doi:10.1016/j.amjsurg.2025.116490
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  Introduction: Despite the high risk of fatality from traveling in a motorcycle compared to motor vehicles, only five states have an age limit for motorcycle passengers. Literature is profoundly lacking on injury patterns of motorcycle passengers, particularly children. We studied injury patterns and helmet use for motorcycle passengers in children
• Hartwell, J. L., Sachdeva, S., Lassen, S., Sharp, S., Hartwell, J. R., Baker, J., Chalise, P., Tatebe, L., Anand, T., & Berry, S. (2025). Discordance of Perceptions and Experiences of Trauma Surgeons and Their Families. Journal of the American College of Surgeons.
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  It is unclear how a career in trauma affects a surgeon and their family in terms of the structure of home life, perception of risk, and mental health. While there are studies investigating the effect of working parents and the child development, there are no studies examining the impact upon partners and children of trauma surgeons.
• Hejazi, O., Colosimo, C., Khurshid, M. H., Stewart, C., Al Ma'ani, M., Anand, T., Diaz, F. C., Castanon, L., Magnotti, L. J., & Joseph, B. (2025). Does frailty predict readmission and mortality in diverticulitis? A nationwide analysis. Journal of Trauma and Acute Care Surgery. doi:10.1097/ta.0000000000004707
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  INTRODUCTION: Diverticulitis is a major health concern in the United States affecting up to 25% of elderly population. It is unknown if frailty increases the risk of recurrent diverticulitis. The aim of our study is to identify the association between frailty and recurrence of diverticulitis. METHODS: We performed a retrospective analysis of the Nationwide Readmissions Database 2019 and included geriatric (65 years or older) patients admitted for acute complicated diverticulitis (ACD) who were managed nonoperatively between January and June and had a 6-month follow-up. Patients were stratified into nonfrail, prefrail, and frail groups using the five-factor modified frailty index. Primary outcome was readmission due to ACD or acute uncomplicated diverticulitis (AUD) at 1 and 6 months after the admission. Secondary outcome was mortality. Multivariable regression analysis was performed to identify the predictors of recurrent diverticulitis and outcomes. RESULTS: We identified 10,807 patients (nonfrail, 1,953; prefrail, 4,616; frail, 4,238). No differences were found between the groups in readmissions for recurrent ACD and AUD at 1 month after discharge. However, nonfrail patients and prefrail had higher rates of ACD (p = 0.009) and AUD (p < 0.001) at 6 months after index admission. Frail patients had higher mortality on index admission (p < 0.001) and at 6 months (p < 0.001). On multivariable regression analyses, frailty was a predictor of mortality on index (adjusted odds ratio, 1.99; p < 0.001) and readmissions (adjusted odds ratio, 3.05; p < 0.001). CONCLUSION: Frailty was not identified as a predictor of developing recurrent diverticulitis; however, frail patients are at increased risk of mortality once they develop diverticulitis. Optimal management for frail patients with diverticulitis must be defined to improve outcomes.
• Khurshid, M. H., Al Ma'ani, M., Hejazi, O., Castillo Diaz, F., Nelson, A., Anand, T., Colosimo, C., Okosun, S. E., Magnotti, L. J., & Joseph, B. (2025). Fibrinogen in Resuscitation of Older Adult Trauma Patients: Are They Too Old to Receive New Adjuncts?. Journal of Surgical Research, 315(Issue). doi:10.1016/j.jss.2025.09.045
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  Introduction: Trauma-induced coagulopathy occurs in a quarter of injured patients and increases the risk of mortality. Recent studies suggest that fibrinogen supplementation (FS), when used as an adjunct for resuscitation, is associated with improved outcomes. There is a lack of data on the role of pharmacologic adjuncts in hemorrhaging older adult (OA) trauma patients. The aim of our study was to compare the outcomes of patients receiving FS as an adjunct to the standard of care among OA versus young adult (YA) trauma patients. Methods: We performed a 4-y (2017-2020) retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database. All adult (age ≥18 y) trauma patients with a shock index > 1 who received early (≤4 h) FS, including fibrinogen concentrate (FC) or cryoprecipitate (Cryo), were included. We excluded patients dead on arrival, those transferred from other facilities, those with bleeding disorders or chronic liver disease, and those on preinjury anticoagulation. Patients were stratified into YA (18-64 y) and OA (≥ 65 y). Primary outcomes were 6-h and 24-h mortality. Secondary outcomes were included in-hospital mortality, major complications, and 4-h blood transfusion requirements. Multivariable regression analyses were performed to identify the independent association of age on the outcomes. Results: A total of 7103 patients were identified, of which 999 (14.06%) were OA. On presentation, the mean shock index was 1.4, and both study groups had comparable median Injury Severity Score. The median time to FC and Cryo administration was 59 and 120 min, respectively. Overall, the rates of 6-h, 24-h, and in-hospital mortality were 11.1%, 20.6%, and 38.9%, respectively. On multivariable regression analysis, age was not associated with 6-h mortality (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI] [0.95-1.52], P = 0.125), 24-h mortality (aOR: 1.12, 95% CI [0.87-1.43], P = 0.379), and major complications (aOR: 0.79, 95% CI [0.83-1.27], P = 0.125). However, OA had independently higher risk-adjusted odds of in-hospital mortality (aOR: 1.96, 95% CI [1.59-2.41], P < 0.001). Notably, older age was associated with a 5.27-unit decrease in packed red blood cell, 2.82-unit decrease in fresh frozen plasma, and 1.63-unit decrease in platelet requirements at 4 h. A subanalysis of patients receiving Cryo (n = 6409) or FC (n = 694) showed the same trend of outcomes. Conclusions: FS was associated with early outcomes that were broadly comparable between OA and YA. Despite higher in-hospital mortality, older age was associated with a reduction in blood product transfusion compared with younger patients.
• Khurshid, M. H., Al Ma'ani, M., Hejazi, O., Castillo Diaz, F., Nelson, A., Anand, T., Colosimo, C., Okosun, S. E., Magnotti, L. J., & Joseph, B. (2025). Fibrinogen in Resuscitation of Older Adult Trauma Patients: Are They Too Old to Receive New Adjuncts?. The Journal of surgical research, 315, 426-434.
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  Trauma-induced coagulopathy occurs in a quarter of injured patients and increases the risk of mortality. Recent studies suggest that fibrinogen supplementation (FS), when used as an adjunct for resuscitation, is associated with improved outcomes. There is a lack of data on the role of pharmacologic adjuncts in hemorrhaging older adult (OA) trauma patients. The aim of our study was to compare the outcomes of patients receiving FS as an adjunct to the standard of care among OA versus young adult (YA) trauma patients.
• Khurshid, M. H., Castillo Diaz, F., Hejazi, O., Al Ma'ani, M., Stewart, C., Spencer, A. L., Anand, T., Kunac, A., Magnotti, L. J., & Joseph, B. (2025). Report Cards Are Out: Nine Years of Nonoperative Management for Blunt Abdominal Solid Organ Trauma. Journal of Surgical Research, 314(Issue). doi:10.1016/j.jss.2025.06.073
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  Introduction: There has been a dramatic shift toward nonoperative management (NOM) of blunt abdominal solid organ injuries (ASOIs) with angioembolization (AE). However, there is a lack of evidence assessing temporal trends in AE use, timing of intervention, and how these trends relate to NOM failure and patient outcomes over time. The aim of this study was to assess the trends in time to AE, its association with failure of NOM, and outcomes of these patients across the United States. Materials and methods: We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database over 9 y, ending in 2021. We included adult patients (age ≥ 18 y) with blunt ASOI (spleen, liver, and kidney) who underwent AE within 4 h of hospital arrival. Patients who underwent operative intervention before AE were excluded. The primary outcome measured was the failure of NOM. Secondary outcomes included major complications, 24-h mortality, and in-hospital mortality. Multivariable regression analyses were performed to identify the independent effect of every hour delay in time to AE on outcomes. Results: A total of 2203 patients with blunt ASOI who were managed nonoperatively with AE were identified. The mean age was 45, and 68% were male. On arrival, the mean systolic blood pressure was 105, and the median Glasgow coma scale was 15. The median Injury Severity Score and abdominal Abbreviated Injury Scale were 25 and 3, respectively. The median 4-h packed red blood cell, fresh frozen plasma, and platelet requirements were 2, 1, and 0, respectively. Overall, spleen was the most common angioembolized abdominal organ (57.3%), followed by the liver (28.9%) and kidney (13.8%). The median time to AE was 156 [114-195] min. Only 8% of patients underwent AE within the first 60 min of arrival. A significantly decreasing trend over the study period was observed in time to AE (2013:180 min versus 2021:105 min, P < 0.001). Among the study population, 19.7% experienced NOM failure, with a median [interquartile range] time to surgery of 5 [3-11] h. Over the years, there was a significant reduction in NOM failure rates (2013:26.2% versus 2021:8.7%, P < 0.001), major complications (2013:57.5% versus 2021:25.1%, P < 0.001), 24-h mortality (2013:6.8% versus 2021:1.3%, P = 0.006), and in-hospital mortality (2013:16.4% versus 2021:8.1%, P = 0.015). On multivariable regression analyses, every hour delay in time to AE was associated with higher odds of NOM failure (adjusted odds ratio [aOR]: 1.13, 95% confidence interval [CI] [1.02-1.16], P = 0.006), major complications (aOR: 1.12, 95% CI [1.02-1.23], P = 0.019), 24-h mortality (aOR: 1.19, 95% CI [1.09-1.52], P = 0.014), and in-hospital mortality (aOR: 1.17, 95% CI [1.01-1.35], P = 0.041). Conclusions: NOM of patients with blunt ASOI has improved over the past 9 y, with failure rates decreasing by approximately 30%, indicating enhanced effectiveness of AE over time. Timely AE was independently associated with lower complication rates and reduced 24-h and in-hospital mortality, likely due to earlier hemorrhage control and mitigation of secondary physiologic decline. Efforts should focus on improving timely access to AE through standardized trauma protocols, early identification of candidates, and streamlined interventional radiology activation.
• Khurshid, M. H., Castillo Diaz, F., Hejazi, O., Al Ma'ani, M., Stewart, C., Spencer, A. L., Anand, T., Kunac, A., Magnotti, L. J., & Joseph, B. (2025). Report Cards Are Out: Nine Years of Nonoperative Management for Blunt Abdominal Solid Organ Trauma. The Journal of surgical research, 314, 49-58.
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  There has been a dramatic shift toward nonoperative management (NOM) of blunt abdominal solid organ injuries (ASOIs) with angioembolization (AE). However, there is a lack of evidence assessing temporal trends in AE use, timing of intervention, and how these trends relate to NOM failure and patient outcomes over time. The aim of this study was to assess the trends in time to AE, its association with failure of NOM, and outcomes of these patients across the United States.
• Khurshid, M. H., Colosimo, C., Hejazi, O., Nelson, A., Al Ma'ani, M., Anand, T., Castillo Diaz, F., Ditillo, M., Magnotti, L. J., & Joseph, B. (2025). Uncovering gender, racial, ethnic, and socioeconomic disparities among adolescent survivors of suicide attempts in trauma centers: Where can we do better?. Journal of Trauma and Acute Care Surgery, 99(Issue). doi:10.1097/ta.0000000000004587
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  BACKGROUND Suicide is the second leading cause of death among adolescents aged 10 years to 17 years. The aim of this study was to examine a nationwide database to identify prevalence, injury patterns, outcomes, and disparities in the receipt of mental health care (MHC) in adolescents presenting following an attempted suicide at US trauma centers (TCs). METHODS This is a 5-year (2017-2021) retrospective cohort analysis of the pediatric ACS-TQIP database. All adolescents (aged 10-17 years) presenting following a suicide attempt were included. Patients with superficial minor lacerations were excluded from the study. Outcomes measured were mortality rate among all adolescent patients who presented following a suicide attempt and rates of receiving MHC among survivors. Backward stepwise regression analyses were performed to identify predictors of outcomes. RESULTS A total of 3,738 adolescent patients presented to TCs after an attempt at suicide. The prevalence of suicide attempts increased (13.8 cases/1000 TC discharges in 2017 to 14.2 cases/1000 TC discharges in 2021; p < 0.001). Overall, 27% died during the index admission. Among survivors, the median age was 15 years, 64.8% patients were White, 15.6% Black, 16.0% Hispanic, 5.6% uninsured, and 37% were treated at a verified pediatric TC. Overall, 42.7% had a preinjury mental disorder. The most common mechanism of injury was cut/stab (28.3%), followed by firearms (24.3%), blunt mechanisms (20.9%), and asphyxiation (6.4%). Only 36% of survivors received MHC during index admission or on discharge. Firearm injuries, male gender, uninsured status, and Hispanic ethnicity were independent predictors of mortality. Moreover, male gender, Black race, Hispanic ethnicity, uninsured patients, and nonpediatric-verified TCs were associated with lower adjusted odds of receiving MHC. CONCLUSION The reported rate of violent suicide attempts in TC increased significantly over the years across the United States. There is a need for improved access to MHC for suicide attempt survivors. Our findings can serve to inform trauma registry data and policymakers by defining suicide attempt patterns and outcomes. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
• Morris, P., Topper, G. V., Metheny, J., Plumb, J., Ratnasekera, A., Anand, T., Voytik, M., Hess, T., Nation, R. J., Sofield, H., Hunter, K., & Egodage, T. (2025). Use of Whole Blood in Trauma Patients on Anticoagulation or Antiplatelet Therapy. The Journal of surgical research, 317, 305-312.
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  Anticoagulation and antiplatelet (AC/AP) medications complicate hemorrhage control and are associated with increased mortality in trauma. Whole blood (WB) may be associated with different outcomes for hemorrhaging patients over component therapy (CT). We hypothesize that in hemorrhaging patients on AC/AP, WB is associated with improved outcomes over CT transfusion.
• O'Connor, D., Hejazi, O., Colosimo, C., Stewart, C., Hosseinpour, H., Khurshid, M. H., Nelson, A. C., Joseph, B., Bhogadi, S. K., Anand, T., Spencer, A. L., & Magnotti, L. J. (2025). Corrigendum to “Role of endovascular management on outcomes in patients with traumatic inferior vena cava injuries” [Am J Surg 238 (2024) 115836] (The American Journal of Surgery (2024) 238, (S000296102400388X), (10.1016/j.amjsurg.2024.115836)). American Journal of Surgery, 250(Issue). doi:10.1016/j.amjsurg.2025.116358
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  The authors regret that the name of one of the co-authors was incorrectly published as. Hamid Hosseinpour. The correct name is [Last name: Hosseinpour, First name: Hamidreza] Muhamad Khurshid. The correct name is [Last name: Khurshid, First name: Muhammad Haris] The authors would like to apologise for any inconvenience caused.
• Ratnasekera, A., Colosimo, C., Battan-Wraith, S., Harris, M., Rubino, M. S., & Anand, T. (2025). Impact of private equity on graduate medical education: A slippery slope. American Journal of Surgery, 243(Issue). doi:10.1016/j.amjsurg.2024.116160
• Yang, A. R., Lundy, M., Otaibi, B., Johnson, K. G., Roberts, H. S., Mahankali, P., Colosimo, C., Magnotti, L. J., Joseph, B., & Anand, T. (2025). Triage of the injured older adult: A narrative review of nationwide hospital practices. American journal of surgery, 249, 116615.
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  Despite published Best Practice Guidelines, a standardized triaging system for older adult trauma patients is not nationally implemented. We conducted a narrative review and consolidated the literature on nationwide triage practices for injured older adults to identify effective components. Search terms included "geriatric hospital triage," "geriatric trauma triage," "elderly trauma triage," and "older adult trauma triage." We included studies conducted in the United States published from 2014 to 2024, which yielded 31 articles. Identified triaging criteria such as anticoagulation, certain comorbidities, fall mechanism, head trauma, and mental status led to improved patient outcomes, such as significantly reduced hospital length of stay and decreased odds of mortality. The parameters for defining and triaging injured older adults are not uniform; however, they could serve as adequate risk stratification or prognostic tools. Effective components of institutional practices comprise a comprehensive triaging system for these patients. Future guidelines should incorporate a consensus of age and physiological criteria of older adults.
• 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
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  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
• Ali Farhan, S., Hasnain, N., Moorpani, M., Sajid, E. U., Shahid, I., Anand, T., & Khosa, F. (2024). Gender Disparity in Academic Trauma Surgery: The Current State of Affairs. The American surgeon, 31348241256080.
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  Despite the increasing number of female surgeons in general surgery programs, women are still inadequately represented in leadership positions. This study aims to investigate the magnitude of gender bias in university-based trauma surgery fellowship programs and leadership positions in the United States of America.
• Ali Farhan, S., Hasnain, N., Moorpani, M., Sajid, E. U., Shahid, I., Anand, T., & Khosa, F. (2024). Gender Disparity in Academic Trauma Surgery: The Current State of Affairs. The American surgeon, 90(Issue 11). doi:10.1177/00031348241256080
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  INTRODUCTION: Despite the increasing number of female surgeons in general surgery programs, women are still inadequately represented in leadership positions. This study aims to investigate the magnitude of gender bias in university-based trauma surgery fellowship programs and leadership positions in the United States of America. MATERIAL AND METHODS: FRIEDA was used to identify trauma surgery programs. A thorough website review of each program obtained further information on faculty members, including their name, age, gender, and faculty rank. Trauma surgeons with an MD or DO qualification and a faculty rank of Professor, Associate Professor, or Assistant Professor were selected for inclusion in this study. SCOPUS was used to assess the H-index and the number of publications and citations of surgeons. RESULTS: The total number of programs included was 136, consisting of 715 faculty members. Less than a quarter (n = 166; 23.2%) comprised females and less than one-fifth (n = 30; 19%) of female surgeons were Professors. The difference in the research productivity of male and female trauma surgeons was statistically significant (P < .05), with the average H-index being 10 vs 7.5, respectively, amongst the top 50 surgeons of both genders. Based on a multiple regression analysis, academic rank was significantly associated (P < .05), and gender was not significantly associated (P > .05) with H-index. CONCLUSION: Gender disparity exists in the field of trauma surgery, as noted in senior faculty ranks and leadership positions. Female-inclusive state policies, appropriate mentorship, and supportive institutions can help to bridge this gap.
• Alizai, Q., Arif, M., Colosimo, C., Hosseinpour, H., Spencer, A., Bhogadi, S., Nelson, A., Anand, T., Ditillo, M., & Joseph, B. (2024). Beyond the short-term relief: Outcomes of geriatric rib fracture patients receiving paravertebral nerve blocks and epidural analgesia. Injury, 55(1). doi:10.1016/j.injury.2023.111184
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  Background: Adequate pain control is a critical component of rib fracture management. Our study aimed to evaluate the in-hospital and post-discharge outcomes of geriatric rib fracture patients who received paravertebral nerve block (PVNB) versus epidural analgesia (EA) on a national level. Methods: We performed a 5-year (2011–15) retrospective analysis of the Nationwide Readmission database. We included all the geriatric (≥65 years) blunt trauma patients with rib fractures who received a paravertebral nerve block (PVNB) or Epidural analgesia (EA) for chest injuries. We excluded patients who were dead on arrival, those with head AIS≥3, spine AIS >0, and those with cognitive impairment. Patients were stratified into two groups (PVNB and EA). A propensity score matching (1:2) was performed, and the two groups were compared. Our outcomes included delirium, hospital length of stay (LOS), 90-day readmissions, 90-day mechanical ventilation, and initial and 90-day mortality. Results: A total of 2,855 geriatric rib fracture patients were identified, out of which 352 (12 %) received PVNB and 2,503 (87 %) received EA. The mean (SD) age was 78 (8) years and 53 % were female. A total of 1,041 patients were matched (PVNB=347, EA=694 patients). The median [IQR] Injury severity score was 9 [3–15], median chest AIS was 3 [2–4], and 70 % had ≥3 rib fractures. The total mortality during index admission was 6 %, 13 % experienced delirium, and the median hospital LOS was 6 [4–10] days. There was no difference in the primary outcomes of the two groups including rates of index admission mortality (PVNB: 5.2% vs. EA:6.3 %, p = 0.548) and delirium (PVNB: 12.4% vs. EA:12.9 %, p = 0.862). We also found no statistically significant difference between these groups in terms of 90-day respiratory complications (p = 1.000), 90-day readmission (p = 0.111), 90-day mortality (p = 0.718), and 90-day need for mechanical ventilation (p = 1.000). Conclusion: The use of PVNB in geriatric trauma patients with multiple rib fractures is associated with comparable in-hospital and post-discharge outcomes relative to EA. PVNB is relatively easy to perform and has a better side effect profile. The use of PVNB as part of rib fracture management protocols warrants further consideration. Level of evidence: III Study type: Therapeutic/Care Management
• Anand, T., Crawford, A., Sjoquist, M., Hashmi, Z., Richter, R., Joseph, B., & Richter, J. (2024). Decreased Glycocalyx Shedding on Presentation in Hemorrhaging Geriatric Trauma Patients. Journal of Surgical Research, 293. doi:10.1016/j.jss.2023.09.047
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  Introduction: Plasma levels of syndecan-1 (Sdc-1), a biomarker of endothelial glycocalyx (EG) damage, correlate with worse outcomes in trauma patients. However, EG injury is not well characterized in injured older adults (OA). The aims of this study were to characterize Sdc-1 shedding in OA trauma patients relative to younger adults (YA) and determine associations with putative regulators of EG sheddases. Methods: We performed a secondary analysis of data from the Pragmatic, Randomized Optimal Platelet, and Plasma Ratios (PROPPR) trial, stratifying bluntly injured subjects into OA and YA groups based on upper age quartile (57 y). Plasma Sdc-1 levels were compared in OA and YA at hospital arrival through postinjury day 3, and the independent association between age and Sdc-1 level at arrival was determined after adjusting for differences in gender, shock index (SI), and pre-existing comorbidities. In a follow-up analysis, case-control matching was used to create populations of OA and YA with equivalent SI and injury severity score. Levels of Sdc-1 were compared between these matched groups, and the relationships with candidate regulators of EG shedding were assessed. Results: Of 680 subjects in the Pragmatic, Randomized Optimal Platelet, and Plasma Ratios trial, 350 (51%) had blunt injuries, and 92 (26.3%) of these were OA. Plasma Sdc-1 levels at arrival, 2 h, and 6 h were significantly lower in OA compared to YA (all P < 0.05). After adjusting for sex, pre-existing morbidities and SI, age was associated with decreased Sdc-1 levels at arrival. In the matched analyses, Sdc-1, high-mobility group box 1 and tissue inhibitor of metalloproteinase–2 levels were lower in OA compared to YA. Both high-mobility group box-1 and tissue inhibitor of metalloproteinase–2 significantly correlated with arrival Sdc-1 and were inversely associated with age. Conclusions: This study indicates that increased age is independently associated with decreased Sdc-1 levels among patients with blunt injuries. Suppressed plasma levels of sheddases in relation to diminished Sdc-1 shedding suggest that mechanisms regulating EG cleavage may be impaired in injured older adults. These findings provide novel insight into the age-dependent impact of injury on the vascular endothelium, which could have important implications for the clinical management of older adults following trauma.
• Anand, T., Hejazi, O., Conant, M., Joule, D., Lundy, M., Colosimo, C., Spencer, A., Nelson, A., Magnotti, L., & Joseph, B. (2024). Impact of resuscitation adjuncts on postintubation hypotension in patients with isolated traumatic brain injury. Journal of Trauma and Acute Care Surgery, 97(Issue 1). doi:10.1097/ta.0000000000004306
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  INTRODUCTION Postintubation hypotension (PIH) is a risk factor of endotracheal intubation (ETI) after injury. For those with traumatic brain injury (TBI), one episode of hypotension can potentiate that injury. This study aimed to identify the resuscitation adjuncts that may decrease the incidence of PIH in this patient population. METHODS This is a 4-year (2019-2022) prospective observational study at a level I trauma center. Adult (18 years or older) patients with isolated TBI requiring ETI in the trauma bay were included. Blood pressures were measured 15 minutes preintubation and postintubation. Primary outcome was PIH, defined as a decrease in systolic blood pressure of ≥20% from baseline or to ≤80 mm Hg, or any decrease in mean arterial pressure to ≤60 mm Hg. Multivariable logistic regression was performed to identify the associations of preintubation vasopressor, hypertonic saline (HTS), packed red blood cell, and crystalloids on PIH incidence. RESULTS Of the 490 enrolled patients, 16% had mild (head AIS, ≤2), 35% had moderate (head AIS, 3-4), and 49% had severe TBI (head AIS, ≥5). The mean ± SD age was 42 ± 22 years, and 71% were male. The median ISS, head AIS, and Glasgow Coma Scale were 26 (19-38), 4 (3-5), and 6 (3-11), respectively. The mean ± SD systolic blood pressure 15 minutes preintubation and postintubation were 118 ± 46 and 106 ± 45, respectively. Before intubation, 31% received HTS; 10%, vasopressors; 20%, crystalloids; and 14%, at least 1 U of packed red blood cell (median, 2 [1-2] U). Overall, 304 patients (62%) developed PIH. On multivariable regression analysis, preintubation use of vasopressors and HTS was associated with significantly decreased odds of PIH independent of TBI severity, 0.310 (0.102-0.944, p = 0.039) and 0.393 (0.219-0.70, p = 0.002), respectively. CONCLUSION Nearly two thirds of isolated TBI patients developed PIH. Preintubation vasopressors and HTS are associated with a decreased incidence of PIH. Such adjuncts should be considered prior to ETI in patients with suspected TBI.
• Anand, T., Hejazi, O., Conant, M., Joule, D., Lundy, M., Colosimo, C., Spencer, A., Nelson, A., Magnotti, L., & Joseph, B. (2024). Impact of resuscitation adjuncts on postintubation hypotension in patients with isolated traumatic brain injury. The journal of trauma and acute care surgery, 97(1), 112-118.
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  Postintubation hypotension (PIH) is a risk factor of endotracheal intubation (ETI) after injury. For those with traumatic brain injury (TBI), one episode of hypotension can potentiate that injury. This study aimed to identify the resuscitation adjuncts that may decrease the incidence of PIH in this patient population.
• Anand, T., Hejazi, O., Nelson, A., Litmanovich, B., Spencer, A. L., Khurshid, M. H., Ghaedi, A., Hosseinpour, H., Magnotti, L. J., & Joseph, B. (2024). Early Vasopressor Requirement Among Hypotensive Trauma Patients: Does It Cause More Harm Than Good?. The American surgeon, 31348241269425.
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  Optimal utilization of vasopressors during early post-injury resuscitation remains unclear. Our study aims to describe the relationship between the timing of vasopressor administration and outcomes among hypotensive trauma patients.
• Anand, T., Hosseinpour, H., Ditillo, M., Bhogadi, S. K., Akl, M. N., Collins, W. J., Magnotti, L. J., & Joseph, B. (2024). The Importance of Circulation in Airway Management: Preventing Post-Intubation Hypotension in The Trauma Bay. Annals of surgery.
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  To identify the modifiable and non-modifiable risk factors associated with post-intubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay.
• Bhogadi, S. K., Ditillo, M., Khurshid, M. H., Stewart, C., Hejazi, O., Spencer, A. L., Anand, T., Nelson, A., Magnotti, L. J., & Joseph, B. (2024). Development and Validation of Futility of Resuscitation Measure in Older Adult Trauma Patients. Journal of Surgical Research, 301(Issue). doi:10.1016/j.jss.2024.07.019
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  Introduction: This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients. Methods: This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2018) (derivation cohort) and American College of Surgeons level I trauma center database (2017-2022) (validation cohort). We included all severely injured (injury severity score >15) older adult (aged ≥60 y) trauma patients. Patients were stratified into decades of age. Injury characteristics (severe traumatic brain injury [Glasgow Coma Scale ≤ 8], traumatic brain injury midline shift), physiologic parameters (lowest in-hospital systolic blood pressure [≤1 h], prehospital cardiac arrest), and interventions employed (4-h packed red blood cell transfusions, emergency department resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta, emergency laparotomy [≤2 h], early vasopressor requirement [≤6 h], and craniectomy) were identified. Regression coefficient-based weighted scoring system was developed using the Schneeweiss method and subsequently validated using institutional database. Results: A total of 5562 patients in derivation cohort and 873 in validation cohort were identified. Mortality was 31% in the derivation cohort and FoRM had excellent discriminative power to predict mortality (area under the receiver operator characteristic = 0.860; 95% confidence interval [0.847-0.872], P < 0.001). Patients with a FoRM score of >16 had a less than 10% chance of survival, while those with a FoRM score of >20 had a less than 5% chance of survival. In validation cohort, mortality rate was 17% and FoRM had good discriminative power (area under the receiver operator characteristic = 0.76; 95% confidence interval [0.71-0.80], P < 0.001). Conclusions: FoRM can reliably identify the risk of futile resuscitation among older adult patients admitted to our level I trauma center.
• Bhogadi, S. K., Ditillo, M., Khurshid, M. H., Stewart, C., Hejazi, O., Spencer, A. L., Anand, T., Nelson, A., Magnotti, L. J., & Joseph, B. (2024). Development and Validation of Futility of Resuscitation Measure in Older Adult Trauma Patients. The Journal of surgical research, 301, 591-598.
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  This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients.
• Bhogadi, S. K., El-Qawaqzeh, K., Colosimo, C., Hosseinpour, H., Magnotti, L. J., Spencer, A. L., Anand, T., Ditillo, M., Alizai, Q., Nelson, A., & Joseph, B. (2024). Pediatric Acute Compartment Syndrome in Long Bone Fractures: Who is at Risk?. Journal of Surgical Research, 298(Issue). doi:10.1016/j.jss.2024.01.032
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  Introduction: There is a paucity of large-scale data on the factors that suggest an impending or underlying extremity pediatric acute compartment syndrome (ACS). In addition, literature regarding the timing of operative fixation and the risk of ACS is mixed. We aimed to describe the factors associated with pediatric ACS. Methods: Analysis of 2017-2019 Trauma Quality Improvement Program. We included patients aged
• Bhogadi, S. K., El-Qawaqzeh, K., Colosimo, C., Hosseinpour, H., Magnotti, L. J., Spencer, A. L., Anand, T., Ditillo, M., Alizai, Q., Nelson, A., & Joseph, B. (2024). Pediatric Acute Compartment Syndrome in Long Bone Fractures: Who is at Risk?. The Journal of surgical research, 298, 53-62.
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  There is a paucity of large-scale data on the factors that suggest an impending or underlying extremity pediatric acute compartment syndrome (ACS). In addition, literature regarding the timing of operative fixation and the risk of ACS is mixed. We aimed to describe the factors associated with pediatric ACS.
• Bhogadi, S. K., Hejazi, O., Nelson, A., Stewart, C., Hosseinpour, H., Spencer, A. L., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Surgical stabilization of rib fractures: The impact of volume and the need for standardized indications. American Journal of Surgery, 234(Issue). doi:10.1016/j.amjsurg.2024.03.019
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  Introduction: We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF. Methods: Blunt rib fracture patients who underwent SSRF were included from ACS-TQIP2017-2021. TCs were stratified according to tertiles of SSRF volume:low (LV), middle, and high (HV). Outcomes were time to SSRF, respiratory complications, prolonged ventilator use, mortality. Results: 16,872 patients were identified (LV:5470,HV:5836). Mean age was 56 years, 74% were male, median thorax-AIS was 3. HV centers had a lower proportion of patients with flail chest (HV41% vs LV50%), pulmonary contusion (HV44% vs LV52%) and had shorter time to SSRF(HV58 vs LV76 ​h), less respiratory complications (HV3.2% vs LV4.5%), prolonged ventilator use (HV15% vs LV26%), mortality (HV2% vs LV2.6%) (all p ​< ​0.05). On multivariable regression analysis, HV centers were independently associated with reduced time to SSRF(β ​= ​−18.77,95%CI ​= ​−21.30to-16.25), respiratory complications (OR ​= ​0.67,95%CI ​= ​0.49–0.94), prolonged ventilator use (OR ​= ​0.49,95%CI ​= ​0.41–0.59), but not mortality. Conclusions: HV SSRF centers have improved outcomes, however, there are variations in threshold for SSRF and indications must be standardized. Level of evidence: Level III. Study type: Therapeutic/Care Management.
• Bhogadi, S. K., Hejazi, O., Nelson, A., Stewart, C., Hosseinpour, H., Spencer, A. L., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Surgical stabilization of rib fractures: The impact of volume and the need for standardized indications. American journal of surgery, 234, 112-116.
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  We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF.
• Bhogadi, S. K., Nelson, A., Hosseinpour, H., Anand, T., Hejazi, O., Colosimo, C., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Effect of PCC on outcomes of severe traumatic brain injury patients on preinjury anticoagulation. American Journal of Surgery, 232(Issue). doi:10.1016/j.amjsurg.2024.01.035
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  Introduction: This study aims to evaluate effect of 4-factor PCC on outcomes of severe TBI patients on preinjury anticoagulants undergoing craniotomy/craniectomy. Methods: In this analysis of 2018–2020 ACS-TQIP, patients with isolated blunt severe TBI (Head-AIS≥3, nonhead-AIS
• Bhogadi, S. K., Nelson, A., Hosseinpour, H., Anand, T., Hejazi, O., Colosimo, C., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Effect of PCC on outcomes of severe traumatic brain injury patients on preinjury anticoagulation. American journal of surgery, 232, 138-141.
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  This study aims to evaluate effect of 4-factor PCC on outcomes of severe TBI patients on preinjury anticoagulants undergoing craniotomy/craniectomy.
• Colosimo, C., Otaibi, B., Bhogadi, S. K., Nelson, A., Spencer, A. L., Anand, T., Stewart, C., Magnotti, L. J., & Joseph, B. (2024). Obesity is a predictor of abdominal computed tomography imaging in pediatric trauma patients. Journal of Trauma and Acute Care Surgery, 97(Issue 6). doi:10.1097/ta.0000000000004424
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  BACKGROUND Computed tomography (CT) has helped to reduce the morbidity due to missed injuries. However, CT imaging is associated with radiation exposure and thus has limited indications in pediatric patients. In this study, we aimed to identify the association between obesity and abdominal CT imaging in pediatric trauma patients. METHODS We performed a 4-year retrospective analysis of the American College of Surgeons Trauma Quality Improvement 2017-2020. We identified all pediatric trauma patients aged between 7 and 17 years presenting with isolated abdominal trauma (nonabdominal Abbreviated Injury Scale score, 0). We excluded patients undergoing hemorrhage control surgeries and those with missing information in height and weight. Patients were stratified by body mass index into four groups (underweight, normal, overweight, and obese [body mass index, ≥30 kg/m2]). Outcomes were predictors of undergoing CT imaging of the abdomen. Descriptive statistics and multivariable logistic regression analyses were performed. RESULTS We identified a total of 10,204 pediatric trauma patients. The mean age was 13 years, 68% were male, and 77% were White. The median abdominal Abbreviated Injury Scale score in all the four groups was 2. On univariate analysis, underweight patients had lowest rates (25%), whereas obese patients had highest rates of CT imaging (38%) (p < 0.001). On multivariable regression analysis, increasing age (adjusted odds ratio [aOR], 1.08; 95% confidence interval [CI], 1.06-1.10; p < 0.001), male sex (aOR, 1.14; 95% CI, 1.03-1.26; p = 0.009), White race (aOR, 0.84; 95% CI, 0.76-0.92; p < 0.011), penetrating injury (aOR, 1.16; 95% CI, 1.03-1.32; p = 0.017), obesity (aOR, 1.30; 95% CI, 1.07-1.57; p = 0.008), and management at American College of Surgeons level II (aOR, 1.63; 95% CI, 1.44-1.85; p < 0.001) and level III or lower centers (aOR, 1.17; 95% CI, 1.06-1.26; p = 0.002) were identified as independent predictors of receiving CT imaging. CONCLUSION Obesity is associated with increased odds of undergoing CT imaging in pediatric trauma patients independent of injury characteristics. Future efforts to define the appropriate indications for CT imaging in pediatric trauma patients are warranted to reduce the adverse effects of CT radiation. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
• Colosimo, C., Otaibi, B., Bhogadi, S. K., Nelson, A., Spencer, A. L., Anand, T., Stewart, C., Magnotti, L. J., & Joseph, B. (2024). Obesity is a predictor of abdominal computed tomography imaging in pediatric trauma patients. The journal of trauma and acute care surgery.
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  Computed tomography (CT) has helped to reduce the morbidity due to missed injuries. However, CT imaging is associated with radiation exposure and thus has limited indications in pediatric patients. In this study, we aimed to identify the association between obesity and abdominal CT imaging in pediatric trauma patients.
• Culbert, M. H., Bhogadi, S. K., Hosseinpour, H., Colosimo, C., Alizai, Q., Anand, T., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen. Journal of Surgical Research, 298(Issue). doi:10.1016/j.jss.2023.12.046
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  Introduction: Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen. Methods: In this analysis of 2017-2021 American College of Surgeons-Trauma Quality Improvement Program (ACS TQIP), adult(≥18 y) patients with SUD and positive drug screen who survived the hospital admission were included. Outcomes measure was the receipt of MHS. Poisson regression analysis with clustering by facility was performed to identify independent predictors of receipt of MHS. Results: 128,831 patients were identified of which 3.4% received MHS. Mean age was 41 y, 76% were male, 63% were White, 25% were Black, 12% were Hispanic, and 82% were insured. Median injury severity score was 9, and 54% were managed at an ACS level I trauma center. On regression analysis, female gender (aOR = 1.17, 95% CI = 1.09-1.25), age ≥65 y (aOR = 0.98, 95% CI = 0.97-0.99), White race (aOR = 1.37, 95% CI = 1.28-1.47), Hispanic ethnicity (aOR = 0.84, 95% CI = 0.76-0.93), insured status (aOR = 1.22, 95% CI = 1.13-1.33), and management at ACS level I trauma centers (aOR = 1.47, 95% CI = 1.38-1.57) were independent predictors of receipt of MHS. Conclusions: Race, ethnicity, and socioeconomic factors predict the receipt of MHS in trauma patients with SUD and positive drug screens. It is unknown if these disparities affect the long-term outcomes of these vulnerable patients. Further research is warranted to expand on the contributing factors leading to these disparities and possible strategies to address them.
• Culbert, M. H., Bhogadi, S. K., Hosseinpour, H., Colosimo, C., Alizai, Q., Anand, T., Spencer, A. L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen. The Journal of surgical research, 298, 7-13.
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  Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen.
• Dhanasekara, C. S., Shrestha, K., Grossman, H., Garcia, L. M., Maqbool, B., Luppens, C., Dumas, R. P., Taveras Morales, L. R., Brahmbhatt, T. S., Haqqani, M., Lunevicius, R., Nzenwa, I. C., Griffiths, E., Almonib, A., Bradley, N. L., Lerner, E. P., Mohseni, S., Trivedi, D., Joseph, B. A., , Anand, T., et al. (2024). A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study. Surgery (United States), 176(Issue 3). doi:10.1016/j.surg.2024.03.057
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  Background: Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. Methods: A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. Results: In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. Conclusion: Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.
• Dhanasekara, C. S., Shrestha, K., Grossman, H., Garcia, L. M., Maqbool, B., Luppens, C., Dumas, R. P., Taveras Morales, L. R., Brahmbhatt, T. S., Haqqani, M., Lunevicius, R., Nzenwa, I. C., Griffiths, E., Almonib, A., Bradley, N. L., Lerner, E. P., Mohseni, S., Trivedi, D., Joseph, B. A., , Anand, T., et al. (2024). A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study. Surgery, 176(3), 605-613.
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  Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder.
• 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
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  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
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  Introduction: It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients’ outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes. Study Design: Patients ≥65 years were identified from the Trauma Quality Improvement Program (TQIP) database (2017–2019). Patients transferred, discharged from emergency department (ED), and those with head abbreviated injury scale >3 were excluded. 11-factor modified frailty index was utilized. Propensity score matching (1:1) was performed. Outcomes included discharge to skilled nursing facility or rehab (SNF/rehab), withdrawal of life-supporting treatment (WLST), mortality, complications, failure-to-rescue, intensive care unit (ICU) admission, hospital length of stay (LOS), and ventilator days. Results: 110,680 patients were matched (Frail:55,340, Non-Frail:55,340). Mean age was 79 (7), 90% presented following falls, and median ISS was 5 [2–9]. Level-I/II TCs had lower rates of discharge to SNF/rehab (52.6% vs. 55.8% vs. 60.9%; p < 0.001), failure-to-rescue (0.5% vs. 0.4% vs. 0.6%;p = 0.005), and higher rates of WLST (2.4% vs. 2.1% vs. 0.3%; p < 0.001) compared to level-III regardless of injury severity and frailty. Compared to Level-III centers, Level-I/II centers had higher complications among moderate-to-severely injured patients (4.1% vs. 3.3% vs. 2.7%; p < 0.001), and lower mortality only among frail patients regardless of injury severity (1.8% vs. 1.5% vs. 2.6%; p < 0.001). Patients at Level-I TCs were more likely to be admitted to ICU, and had longer hospital LOS and ventilator days compared to Level-II and III TCs (p < 0.05). Conclusion: Frailty may play an important role when triaging geriatric trauma patients. In fact, the benefit of care at higher-level TCs is particularly evident for patients who are frail. Level III centers may be underperforming in providing access to palliative and end-of-life care.
• Hejazi, O., Spencer, A. L., Khurshid, M. H., Nelson, A., Hosseinpour, H., Anand, T., Bhogadi, S. K., Matthews, M. R., Magnotti, L. J., & Joseph, B. (2024). Failure to Rescue in Geriatric Ground-Level Falls: The Role of Frailty on Not-So-Minor Injuries. Journal of Surgical Research, 302(Issue). doi:10.1016/j.jss.2024.07.095
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  Introduction: The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs). Methods: This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2020). All geriatric (aged ≥ 65 ys) trauma patients with GLFs admitted to a level I trauma center were included. Transferred patients, those with severe head injuries (head abbreviated injury scale ≥ 3), and those who died within 24 h of admission or whose length of stay was ≤1 d were excluded. FTR was defined as death following a major complication (cardiac arrest, myocardial infarction, sepsis, acute respiratory distress syndrome, unplanned intubation, acute renal failure, cerebrovascular accident, ventilator-associated pneumonia, or pulmonary embolism). Patients were stratified into frail (F) and nonfrail (NF) based on the 11-Factor Modified Frailty Index. Multivariable regression analyses were performed to identify the independent effect of frailty on the incidence of FTR. Results: Over 4 ys, 34,100 geriatric patients with GLFs were identified, of whom 9140 (26.8%) were F. The mean (standard deviation) age was 78 (7) years and 65% were female. The median injury severity score was 9 (5-10) with no difference among F and NF groups (P = 0.266). Overall, F patients were more likely to develop major complications (F: 3.6% versus NF: 2%, P < 0.001) and experience FTR (F: 1.8%% versus NF: 0.6%, P < 0.001). Moreover, among patients with major complications, F patients were more likely to die (F: 47% versus NF: 27%, P < 0.001). On multivariable regression analysis, frailty was identified as an independent predictor of major complications (adjusted odds ratio: 1.98, 95% confidence interval [1.70-2.29], P < 0.001) and FTR (adjusted odds ratio: 2.26, 95% confidence interval [1.68-3.05], P < 0.001). Conclusions: Among geriatric trauma patients with GLFs, frailty increases the risk-adjusted odds of FTR by more than two times. One in every two F patients with a major complication does not survive to discharge. Future efforts should concentrate on improving patient-related and hospital-related factors to decrease the risk of FTR among these vulnerable populations.
• Hejazi, O., Spencer, A. L., Khurshid, M. H., Nelson, A., Hosseinpour, H., Anand, T., Bhogadi, S. K., Matthews, M. R., Magnotti, L. J., & Joseph, B. (2024). Failure to Rescue in Geriatric Ground-Level Falls: The Role of Frailty on Not-So-Minor Injuries. The Journal of surgical research, 302, 891-896.
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  The measure of mortality following a major complication (failure to rescue [FTR]) provides a quantifiable assessment of the level of care provided by trauma centers. However, there is a lack of data on the effects of patient-related factors on FTR incidence. The aim of this study was to identify the role of frailty on FTR incidence among geriatric trauma patients with ground-level falls (GLFs).
• Hosseinpour, H., Anand, T., Bhogadi, S. K., Nelson, A., Hejazi, O., Castanon, L., Ghaedi, A., Khurshid, M. H., Magnotti, L. J., Joseph, B., & , A. F. (2024). The implications of poor nutritional status on outcomes of geriatric trauma patients. Surgery, 176(4), 1281-1288.
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  Malnutrition is shown to be associated with worse outcomes among surgical patients, yet its postdischarge outcomes in trauma patients are not clear. This study aimed to evaluate both index admission and postdischarge outcomes of geriatric trauma patients who are at risk of poor nutritional status.
• Hosseinpour, H., Anand, T., Bhogadi, S. K., Nelson, A., Hejazi, O., Castanon, L., Ghaedi, A., Khurshid, M. H., Magnotti, L. J., Joseph, B., Amos, J. D., Teichman, A., Whitmill, M. L., Burruss, S. K., Dunn, J. A., Najafi, K., Godat, L. N., Enniss, T. M., Shoultz, T. H., , Egodage, T., et al. (2024). The implications of poor nutritional status on outcomes of geriatric trauma patients. Surgery (United States), 176(Issue 4). doi:10.1016/j.surg.2024.06.047
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  Background: Malnutrition is shown to be associated with worse outcomes among surgical patients, yet its postdischarge outcomes in trauma patients are not clear. This study aimed to evaluate both index admission and postdischarge outcomes of geriatric trauma patients who are at risk of poor nutritional status. Methods: This is a secondary analysis of the prospective observational American Association of Surgery for Trauma Frailty Multi-institutional Trial. Geriatric (≥65 years) patients presenting to 1 of the 17 Level I/II/III trauma centers (2019–2021) were included and stratified using the simplified Geriatric Nutritional Risk Index (albumin [g/dL] + body mass index [kg/m2]/10) into severe (simplified Geriatric Nutritional Risk Index simplified Geriatric Nutritional Risk Index ≥5), mild level of nutritional risk (6> simplified Geriatric Nutritional Risk Index ≥5.5), and good nutritional status (simplified Geriatric Nutritional Risk Index ≥6) and compared. Results: Of the 1,321 patients enrolled, 22% were at risk of poor nutritional status (mild: 13%, moderate: 7%, severe: 3%). The mean age was 77 ± 8 years, and the median [interquartile range] Injury Severity Score was 9 [5–13]. Patients at risk of poor nutritional status had greater rates of sepsis, pneumonia, discharge to the skilled nursing facility and rehabilitation center, index-admission mortality, and 3-month mortality (P < .05). On multivariable analyses, being at risk of severe level of nutritional risk was independently associated with sepsis (adjusted odds ratio 6.21, 95% confidence interval 1.68–22.90, P = .006), pneumonia (adjusted odds ratio 4.40, 95% confidence interval 1.21–16.1, P = .025), index-admission mortality (adjusted odds ratio 3.16, 95% confidence interval 1.03–9.68, P = .044), and 3-month mortality (adjusted odds ratio 8.89, 95% confidence interval 2.01–39.43, P = .004) compared with good nutrition state. Conclusion: Nearly one quarter of geriatric trauma patients were at risk of poor nutritional status, which was identified as an independent predictor of worse index admission and 3-month postdischarge outcomes. These findings underscore the need for nutritional screening at admission.
• Hosseinpour, H., Anand, T., Hejazi, O., Colosimo, C., Bhogadi, S. K., Spencer, A., Nelson, A., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). The Role of Whole Blood Hemostatic Resuscitation in Bleeding Geriatric Trauma Patients. Journal of Surgical Research, 299(Issue). doi:10.1016/j.jss.2024.03.050
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  Introduction: Whole blood (WB) has recently gained increased popularity as an adjunct to the resuscitation of hemorrhaging civilian trauma patients. We aimed to assess the nationwide outcomes of using WB as an adjunct to component therapy (CT) versus CT alone in resuscitating geriatric trauma patients. Methods: We performed a 5-y (2017-2021) retrospective analysis of the Trauma Quality Improvement Program. We included geriatric (age, ≥65 y) trauma patients presenting with hemorrhagic shock (shock index >1) and requiring at least 4 units of packed red blood cells in 4 h. Patients with severe head injuries (head Abbreviated Injury Scale ≥3) and transferred patients were excluded. Patients were stratified into WB-CT versus CT only. Primary outcomes were 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications. Multivariable regression analysis was performed, adjusting for potential confounding factors. Results: A total of 1194 patients were identified, of which 141 (12%) received WB. The mean ± standard deviation age was 74 ± 7 y, 67.5% were male, and 83.4% had penetrating injuries. The median [interquartile range] Injury Severity Score was 19 [13-29], with no difference among study groups (P = 0.059). Overall, 6-h, 24-h, and in-hospital mortality were 16%, 23.1%, and 43.6%, respectively. On multivariable regression analysis, WB was independently associated with reduced 24-h (odds ratio, 0.62 [0.41-0.94]; P = 0.024), and in-hospital mortality (odds ratio, 0.60 [0.40-0.90]; P = 0.013), but not with major complications (odds ratio, 0.78 [0.53-1.15]; P = 0.207). Conclusions: Transfusion of WB as an adjunct to CT is associated with improved early and overall mortality in geriatric trauma patients presenting with severe hemorrhage. The findings from this study are clinically important, as this is an essential first step in prioritizing the selection of WB resuscitation for geriatric trauma patients presenting with hemorrhagic shock.
• Hosseinpour, H., Anand, T., Hejazi, O., Colosimo, C., Bhogadi, S. K., Spencer, A., Nelson, A., Ditillo, M., Magnotti, L. J., & Joseph, B. (2024). The Role of Whole Blood Hemostatic Resuscitation in Bleeding Geriatric Trauma Patients. The Journal of surgical research, 299, 26-33.
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  Whole blood (WB) has recently gained increased popularity as an adjunct to the resuscitation of hemorrhaging civilian trauma patients. We aimed to assess the nationwide outcomes of using WB as an adjunct to component therapy (CT) versus CT alone in resuscitating geriatric trauma patients.
• Hosseinpour, H., Magnotti, L. J., Huang, D. D., Weinberg, J. A., Tang, A., Hejazi, O., Stewart, C., Bhogadi, S. K., Anand, T., & Joseph, B. (2024). The role of number of affected vessels on radiologic and clinical outcomes of patients with blunt cerebrovascular injury. Journal of vascular surgery, 80(3), 685-692.
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  There is a lack of data on the role of characteristics of injured vessels on the outcomes of patients with blunt cerebrovascular injuries (BCVIs). The aim of this study was to assess the effect of the number (single vs multiple) of injured vessels on outcomes.
• Hosseinpour, H., Nelson, A., Bhogadi, S. K., Magnotti, L. J., 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(Issue). doi:10.1016/j.jss.2024.03.049
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  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., Nelson, A., Bhogadi, S. K., Magnotti, L. J., 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?. The Journal of surgical research, 300, 15-24.
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  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.
• Huang, R., Hejazi, O., Khurshid, M. H., Nelson, A., Stewart, C., Anand, T., Matthews, M. R., Okosun, S. E., Magnotti, L. J., & Joseph, B. (2024). Diversity in crisis: The impact of race and ethnicity on failure to rescue among geriatric trauma patients over the years. Journal of Trauma and Acute Care Surgery, 99(Issue). doi:10.1097/ta.0000000000004514
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  BACKGROUND: Failure to rescue (FTR) is an indicator of the quality of care provided by trauma centers. The aim of this study was to examine the trends of FTR incidence in geriatric trauma patients over the years and to determine whether race, ethnicity, and sex impact the FTR incidence. METHODS: This is a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database over 4 years (2017–2020). All geriatric (≥60 years) trauma patients were included. Patients who died within 24 hours of admission or whose length of stay was ≤1 day were excluded. Trend analysis was performed. Patients were stratified based on race, ethnicity, and sex, and multivariable regression analyses were performed. RESULTS: Over the course of 4 years, 1,105,651 geriatric patients were identified, of whom 30,984 (2.8%) developed major complications and 10,684 (34.5% of those with complications) had FTR. The mean (SD) age was 75 (9) years, 46% were male, 86% were White, and 6% were Hispanic. The median (interquartile range) Injury Severity Score was 9 (4–10) with no change over the years (p = 0.364) and 96.8% sustained a blunt injury. Over the 4 years, the rate of FTR increased from 0.55% in 2017 to 1.04% in 2020 (p < 0.001). An analysis of trends in FTR patients revealed no significant difference in the proportion of males and females over the years (p = 0.482). However, there was a notable increase in the proportion of Black and Hispanic patients in comparison with White (p < 0.001) and non-Hispanic patients (p = 0.023), respectively. The odds of developing FTR have been increasing over the years, with Black race and Hispanic ethnicity identified as the independent risk factors for FTR. CONCLUSION: The risk-adjusted odds of developing FTR have been increasing over the years, with one in every three patients who developed complications not surviving to discharge. Our findings demonstrate that racial and ethnic factors significantly impact the incidence of FTR.
• Joseph, B., Hosseinpour, H., Sakran, J., Anand, T., Colosimo, C., Nelson, A., Stewart, C., Spencer, A. L., Zhang, B., & Magnotti, L. J. (2024). Defining the Problem: 53 Years of Firearm Violence Afflicting America's Schools. Journal of the American College of Surgeons, 238(Issue 4). doi:10.1097/xcs.0000000000000955
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  BACKGROUND: Firearm violence and school shootings remain a significant public health problem. This study aimed to examine how publicly available data from all 50 states might improve our understanding of the situation, firearm type, and demographics surrounding school shootings. STUDY DESIGN: School shootings occurring in the US for 53 years ending in May 2022 were analyzed, using primary data files that were obtained from the Center for Homeland Defense and Security. Data analyzed included situation, injury, firearm type, and demographics of victims and shooters. We compared the ratio of fatalities per wounded after stratifying by type of weapon. Rates (among children) of school shooting victims, wounded, and fatalities per 1 million population were stratified by year and compared over time. RESULTS: A total of 2,056 school shooting incidents involving 3,083 victims were analyzed: 2,033 children, 5 to 17 years, and 1,050 adults, 18 to 74 years. Most victims (77%) and shooters (96%) were male individuals with a mean age of 18 and 19 years, respectively. Of the weapons identified, handguns, rifles, and shotguns accounted for 84%, 7%, and 4%, respectively. Rifles had a higher fatality-to-wounded ratio (0.45) compared with shooters using multiple weapons (0.41), handguns (0.35), and shotguns (0.30). Linear regression analysis identified a significant increase in the rate of school shooting victims (β = 0.02, p = 0.0003), wounded (β = 0.01, p = 0.026), and fatalities (β = 0.01, p = 0.0003) among children over time. CONCLUSIONS: Despite heightened public awareness, the incidence of school shooting victims, wounded, and fatalities among children has steadily and significantly increased over the past 53 years. Understanding the epidemic represents the first step in preventing continued firearm violence in our schools.
• Joseph, B., Hosseinpour, H., Sakran, J., Anand, T., Colosimo, C., Nelson, A., Stewart, C., Spencer, A. L., Zhang, B., & Magnotti, L. J. (2024). Defining the Problem: 53 Years of Firearm Violence Afflicting America's Schools. Journal of the American College of Surgeons, 238(4), 671-678.
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  Firearm violence and school shootings remain a significant public health problem. This study aimed to examine how publicly available data from all 50 states might improve our understanding of the situation, firearm type, and demographics surrounding school shootings.
• Magnotti, L. J., Bhogadi, S. K., Anand, T., Stewart, C., Colosimo, C., Spencer, A. L., Nelson, A., & Joseph, B. (2024). Less Is More: Dissecting Trauma Centers by Procedural Volume. Annals of surgery, 280(4), 667-675.
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  This study aims to examine the relationship between procedural volume and annual trauma volume (ATV) of ACS Level I trauma centers (TC).
• O'Connor, D., Hejazi, O., Colosimo, C., Stewart, C., Hosseinpour, H., Khurshid, M., Nelson, A. C., Joseph, B., Bhogadi, S. K., Anand, T., Spencer, A. L., & Magnotti, L. J. (2024). Role of endovascular management on outcomes in patients with traumatic inferior vena cava injuries. American Journal of Surgery, 238(Issue). doi:10.1016/j.amjsurg.2024.115836
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  Introduction: The aim of this study was to examine the association between the injury mechanism and repair type with outcomes in patients with traumatic inferior vena cava injuries. Methods: This is a retrospective analysis of the ACS-TQIP database (2017–2020), including patients with traumatic IVC injuries. Patients were stratified by injury mechanism and type of repair and compared. Results: Out of 1334 patients, 5 ​% underwent endovascular repair while 95 ​% had an open procedure. Overall, 74.7 ​% sustained a penetrating injury. On multivariable regression analysis, the type of repair was not associated with mortality and morbidity for patients with penetrating injuries. However, among patients with blunt injuries, endovascular repair was associated with lower odds of in-hospital mortality (aOR:0.35, p ​= ​0.020) and non-venous thromboembolism (VTE) morbidity (aOR:0.41, p ​= ​0.015), and higher odds of VTE complications (aOR:6.74, p ​< ​0.001). Conclusions: Although the type of repair did not impact morbidity and mortality in patients with penetrating injuries, endovascular repair was identified as the only modifiable predictor of reduced non-VTE morbidity and mortality in patients with blunt injuries.
• O'Connor, D., Hejazi, O., Colosimo, C., Stewart, C., Hosseinpour, H., Khurshid, M., Nelson, A. C., Joseph, B., Bhogadi, S. K., Anand, T., Spencer, A. L., & Magnotti, L. J. (2024). Role of endovascular management on outcomes in patients with traumatic inferior vena cava injuries. American journal of surgery, 238, 115836.
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  The aim of this study was to examine the association between the injury mechanism and repair type with outcomes in patients with traumatic inferior vena cava injuries.
• Saljuqi, A., Anand, T., & Joseph, B. (2024). Reassessing the economic burden of geriatric falls: a call for preventive action. Trauma Surgery and Acute Care Open, 9(1). doi:10.1136/tsaco-2024-001591
• Spencer, A. L., Hosseinpour, H., Nelson, A., Hejazi, O., Anand, T., Khurshid, M. H., Ghaedi, A., Bhogadi, S. K., Magnotti, L. J., & Joseph, B. (2024). Predicting the time of mortality among older adult trauma patients: Is frailty the answer?. American Journal of Surgery, 237(Issue). doi:10.1016/j.amjsurg.2024.05.009
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  Introduction: This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization. Methods: We performed a 3-year (2017–2019) analysis of ACS-TQIP. We included all older adult (age ≥65 years) trauma patients. Patients were stratified into two groups (Frail vs. Non-Frail). Outcomes were acute (1 week) mortality. Results: A total of 1,022,925 older adult trauma patients were identified, of which 19.7 ​% were frail. The mean(SD) age was 77(8) years and 57.4 ​% were female. Median[IQR] ISS was 9[4–10] and both groups had comparable injury severity (p ​= ​0.362). On multivariable analysis, frailty was not associated with acute (aOR 1.034; p ​= ​0.518) and early (aOR 1.190; p ​= ​0.392) mortality, while frail patients had independently higher odds of intermediate (aOR 1.269; p ​= ​0.042) and late (aOR 1.835; p ​< ​0.001) mortality. On sub-analysis, our results remained consistent in mild, moderate, and severely injured patients. Conclusion: Frailty is an independent predictor of mortality in older adult trauma patients who survive the initial 3 days of admission, regardless of injury severity.
• Spencer, A. L., Hosseinpour, H., Nelson, A., Hejazi, O., Anand, T., Khurshid, M. H., Ghaedi, A., Bhogadi, S. K., Magnotti, L. J., & Joseph, B. (2024). Predicting the time of mortality among older adult trauma patients: Is frailty the answer?. American journal of surgery, 237, 115768.
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  This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization.
• Zambetti, B. R., Nelson, A. C., Hosseinpour, H., Anand, T., Colosimo, C., Spencer, A. L., Stewart, C., Bhogadi, S. K., Hejazi, O., Joseph, B., & Magnotti, L. J. (2024). The optimal management of blunt aortic injury in the young. American Journal of Surgery, 237(Issue). doi:10.1016/j.amjsurg.2024.115943
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  Background: Blunt aortic injury (BAI) is relatively uncommon in the pediatric population. The goal of this study was to examine the management of BAI in both children and adolescents, using a large national dataset. Methods: Patients (1–19 years of age) with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 14-years. Patients were stratified by age group (children [ages 1–9] and adolescents [ages 10–19]) and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in adolescents with BAI. Results: Adolescents undergoing TEVAR had similar morbidity (16.8 vs 12.6 ​%, p ​= ​0.057) and significantly reduced mortality (2.1 vs 14.4 ​%, p ​< ​0.0001) compared to those adolescents managed non-operatively. MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (OR 0.138; 95%CI 0.059–0.324, p ​< ​0.0001). Conclusions: BAI leads to significant morbidity and mortality for both children and adolescents. For pediatric patients with BAI, children may be safely managed non-operatively, while an endovascular repair may improve outcomes for adolescents.
• Zambetti, B. R., Nelson, A. C., Hosseinpour, H., Anand, T., Colosimo, C., Spencer, A. L., Stewart, C., Bhogadi, S. K., Hejazi, O., Joseph, B., & Magnotti, L. J. (2024). The optimal management of blunt aortic injury in the young. American journal of surgery, 237, 115943.
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  Blunt aortic injury (BAI) is relatively uncommon in the pediatric population. The goal of this study was to examine the management of BAI in both children and adolescents, using a large national dataset.
• 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.
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  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(Issue 5). doi:10.1016/j.amjsurg.2023.07.027
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  Background: Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries. Methods: We analyzed the 2017 Nationwide Readmissions Database on adult (≥18 years) trauma patients with pancreatic injuries. Patients who died on index admission were excluded. Patients were stratified into operative (OP) and non-operative (NOP) groups and compared for outcomes within 90 days of discharge. Multivariable regression analyses were performed. Results: We identified 1553 patients (NOP ​= ​1092; OP ​= ​461). The Mean (SD) age was 39 (17.0) years, 31% of patients were female, and 77% had blunt injuries. Median ISS was 17 [9–25] and 74% had concomitant non-pancreatic intraabdominal injuries. On multivariable analysis, operative management was independently associated with increased odds of 90-day readmissions (aOR ​= ​1.47; p ​= ​0.03), intraabdominal abscesses (aOR ​= ​2.7; p ​< ​0.01), pancreatic pseudocyst (aOR ​= ​2.4; p ​= ​0.04), and need for percutaneous or endoscopic management (aOR ​= ​5.8; p ​< ​0.001). Conclusion: Operative management of pancreatic injuries is associated with higher rates of delayed complications compared to non-operative management. Surgically treated pancreatic trauma patients may need close surveillance even after discharge.
• Alizai, Q., Anand, T., Bhogadi, S. K., Nelson, A., Hosseinpour, H., Stewart, C., Spencer, A. L., Colosimo, C., Ditillo, M., & Joseph, B. (2023). From surveillance to surgery: The delayed implications of non-operative and operative management of pancreatic injuries. American journal of surgery, 226(5), 682-687.
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  Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries.
• Alizai, Q., Arif, M. S., Colosimo, C., Hosseinpour, H., Spencer, A. L., Bhogadi, S. K., Nelson, A., Anand, T., Ditillo, M., & Joseph, B. (2023). Beyond the short-term relief: Outcomes of geriatric rib fracture patients receiving paravertebral nerve blocks and epidural analgesia. Injury, 111184.
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  Adequate pain control is a critical component of rib fracture management. Our study aimed to evaluate the in-hospital and post-discharge outcomes of geriatric rib fracture patients who received paravertebral nerve block (PVNB) versus epidural analgesia (EA) on a national level.
• Anand, T., & Joseph, B. (2023). Linguistic discordance: Factors go beyond language. American Journal of Surgery, 225(Issue 6). doi:10.1016/j.amjsurg.2022.11.016
• Anand, T., & Joseph, B. (2023). Linguistic discordance: Factors go beyond language. American journal of surgery, 225(6), 946-947.
• Anand, T., Crawford, A. E., Sjoquist, M., Hashmi, Z. G., Richter, R. P., Joseph, B., & Richter, J. R. (2023). Decreased Glycocalyx Shedding on Presentation in Hemorrhaging Geriatric Trauma Patients. The Journal of surgical research, 293, 709-716.
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  Plasma levels of syndecan-1 (Sdc-1), a biomarker of endothelial glycocalyx (EG) damage, correlate with worse outcomes in trauma patients. However, EG injury is not well characterized in injured older adults (OA). The aims of this study were to characterize Sdc-1 shedding in OA trauma patients relative to younger adults (YA) and determine associations with putative regulators of EG sheddases.
• 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.
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  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.
• Anand, T., Reyes, A. A., Sjoquist, M. C., Magnotti, L., & Joseph, B. (2023). Resuscitating the Endothelial Glycocalyx in Trauma and Hemorrhagic Shock. Annals of surgery open : perspectives of surgical history, education, and clinical approaches, 4(3), e298.
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  The endothelium is lined by a protective mesh of proteins and carbohydrates called the endothelial glycocalyx (EG). This layer creates a negatively charged gel-like barrier between the vascular environment and the surface of the endothelial cell. When intact the EG serves multiple functions, including mechanotransduction, cell signaling, regulation of permeability and fluid exchange across the microvasculature, and management of cell-cell interactions. In trauma and/or hemorrhagic shock, the glycocalyx is broken down, resulting in the shedding of its individual components. The shedding of the EG is associated with increased systemic inflammation, microvascular permeability, and flow-induced vasodilation, leading to further physiologic derangements. Animal and human studies have shown that the greater the severity of the injury, the greater the degree of shedding, which is associated with poor patient outcomes. Additional studies have shown that prioritizing certain resuscitation fluids, such as plasma, cryoprecipitate, and whole blood over crystalloid shows improved outcomes in hemorrhaging patients, potentially through a decrease in EG shedding impacting downstream signaling. The purpose of the following paragraphs is to briefly describe the EG, review the impact of EG shedding and hemorrhagic shock, and begin entertaining the notion of directed resuscitation. Directed resuscitation emphasizes transitioning from macroscopic 1:1 resuscitation to efforts that focus on minimizing EG shedding and maximizing its reconstitution.
• 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(Issue 6). doi:10.1016/j.amjsurg.2022.11.031
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  Introduction: 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. Methods: Analysis of the 2017 NRD. Adults (≥18 years) with a primary diagnosis of spinal fracture who were managed non-operatively were included. Patients that died on index admission, were on pre-injury anticoagulants, and those with spinal cord injuries were excluded. Outcomes were rates of DVT, PE, and VTE during index admission, and at 1-month and 6-months after discharge. Multivariate regression analysis was performed to identify independent predictors of 6-month readmission with VTE. Results: 41,337 patients were identified. Mean age was 61 ± 22 years, and the median ISS was 17[9–22]. Vertebral fractures were: 11% sacrococcygeal; 29% lumbar; 19% thoracic; 20% cervical; and 21% multiple levels. During the index admission, 392(0.9%) patients developed DVT, 281(0.7%) developed PE, and 601(1.5%) VTE. Within 1-month of discharge, 177(0.4%) patients were readmitted with DVT, 142(0.3%) with PE, and 268(0.6%) with VTE. Within 6-months of discharge, 352(0.9%) patients were readmitted with DVT, 250(0.6%) with PE, and 513(1.2%) with VTE. Among those who were readmitted within 6-months with VTE, mortality was 6.7%. On multivariate analysis, older age(OR = 1.01,p < 0.01), higher ISS(OR = 1.03,p < 0.001), thoracic level of spinal fracture(OR = 1.37,p = 0.04), and discharge to skilled nursing facility, rehabilitation center, or care facility(OR = 1.73,p < 0.001) were independently associated with 6-month readmission due to VTE. Conclusions: VTE risk and associated mortality remains high for 6-months after non-operatively managed traumatic spinal fracture. Further studies regarding optimal duration and choice of thromboprophylactic agents are warranted.
• Avila, M., Bhogadi, S. K., Nelson, A., Hosseinpour, H., Ditillo, M., Akl, M., Anand, T., Spencer, A. L., Magnotti, L. J., & Joseph, B. (2023). The long-term risks of venous thromboembolism among non-operatively managed spinal fracture patients: A nationwide analysis. American journal of surgery, 225(6), 1086-1090.
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  Long-term readmission data for venous thromboembolism (VTE) after spinal fractures is limited. We aimed to evaluate the 1-month and 6-month VTE readmission rates in non-operatively managed traumatic spinal fractures.
• Barach, P., Ahmed, R., Agarwal, G., Olson, K., Welch, J. L., Chernoby, K., Hein, C., Anand, T., Joseph, B., Rosenstein, D. L., Sotto-Santiago, S., Hartsock, J. A., Holmes, E., Schroeder, K., & Hartwell, J. L. (2023). Navigating Personal Health Crises, Imposter Syndrome, Sexual Harassment, Clinical Mistakes and Leadership Challenges: Lessons for Work-Life Wellness in Academic Medicine: Part 3 of 3. Kansas Journal of Medicine. doi:10.17161/kjm.vol16.19954
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  In this final manuscript of the three-part series, the authors address issues of imposter syndrome, pregnancy, and parental leave, second victim phenomenon, sexual harassment, response to suicide, and managing a budget while advancing diversity, equity, and inclusion. The case scenarios have learners and non-clinicians as their main characters, bringing attention to the cross-cutting nature of the complex issues we see both in and around a career in medicine.
• Bhogadi, S. K., Magnotti, L. J., Hosseinpour, H., Anand, T., El-Qawaqzeh, K., Nelson, A., Colosimo, C., Spencer, A. L., Friese, R., & Joseph, B. (2023). The final decision among the injured elderly, to stop or to continue? Predictors of withdrawal of life supporting treatment. The journal of trauma and acute care surgery, 94(6), 778-783.
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  There is a paucity of data on factors that influence the decision regarding withdrawal of life supporting treatment (WLST) in geriatric trauma patients. We aimed to identify predictors of WLST in geriatric trauma patients.
• Bhogadi, S. K., Nelson, A., El-Qawaqzeh, K., Spencer, A. L., Hosseinpour, H., Castanon, L., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Does preinjury anticoagulation worsen outcomes among traumatic hemothorax patients? A nationwide retrospective analysis. Injury, 54(9), 110850.
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  Up to a quarter of all traumatic deaths are due to thoracic injuries. Current guidelines recommend consideration of evacuation of all hemothoraces with tube thoracostomy. The aim of our study was to determine the impact of pre-injury anticoagulation on outcomes of traumatic hemothorax patients.
• Bhogadi, S. K., 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(Issue 9). doi:10.1016/j.injury.2023.110850
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  Introduction: 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. Materials and Methods: We performed a 4-year (2017 – 2020) analysis of the ACS-TQIP database. We included all adult trauma patients (age ≥18 years) presenting with hemothorax and no other severe injuries (other body regions once), overall complications, hospital length of stay (LOS), and mortality. Results: A matched cohort of 6,962 patients (AC, 3,481; No-AC, 3,481) was analyzed. The median age was 75 years, and the median ISS was 10. The AC and No-AC groups were similar in terms of baseline characteristics. Compared to the No-AC group, AC group had higher rates of chest tube placement (46% vs 43%, p = 0.018), overall complications (8% vs 7%, p = 0.046), and longer hospital LOS (7[4–12] vs 6[3–10] days, p ≤ 0.001). Reintervention and mortality rates were similar between the groups (p>0.05). Conclusion: The use of preinjury anticoagulants in hemothorax patients negatively impacts patient outcomes. Increased surveillance is required while dealing with hemothorax patients on pre-injury anticoagulants, and consideration should be given to earlier interventions for such 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.
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  Hospitalized burn patients are at increased risk for venous thromboembolism (VTE). Guidelines regarding thromboprophylaxis in burn patients are unclear. This study aims to compare the outcomes of early versus late thromboprophylaxis initiation in burn patients. In this 3-year analysis of 2017-2019 ACS-TQIP, adult(18-64years) burn patients were identified after applying inclusion/exclusion criteria and stratified based on timing of initiation of VTE prophylaxis: Early(24 hours). Outcomes were deep venous thrombosis(DVT), pulmonary embolism(PE), unplanned return to operating room (OR), unplanned intensive care unit (ICU) admission, post-prophylaxis packed red blood cells (PRBC) transfusion, and mortality. Nine thousand two hundred and seventy-two patients were identified. Overall, median age was 41years, 71.5% were male, and median[IQR] injury severity score was 3[1-8]. 53% had second-degree burns, and 80% had less than 40% of total body surface area affected. Median time to thromboprophylaxis initiation was 11[6-20.6]hours. Overall VTE rate was 0.9% (DVT-0.7%, PE-0.2%). On univariable analysis, early prophylaxis group had lower rates of DVT(0.6% vs 1.1%, P = .025), and PE(0.1% vs 0.6%, P < .001). On multivariable regression, late prophylaxis was associated with 1.8 times higher odds of DVT (aOR = 1.8, 95% CI = 1.04-3.11, P = .03), 4.8 times higher odds of PE(aOR = 4.8, 95% CI = 1.9-11.9, P 
• Castanon, L., Krishna Bhogadi, S., 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 and Research, 44(Issue 6). doi:10.1093/jbcr/irad074
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  Hospitalized burn patients are at increased risk for venous thromboembolism (VTE). Guidelines regarding thromboprophylaxis in burn patients are unclear. This study aims to compare the outcomes of early versus late thromboprophylaxis initiation in burn patients. In this 3-year analysis of 2017–2019 ACS-TQIP, adult(18–64years) burn patients were identified after applying inclusion/exclusion criteria and stratified based on timing of initiation of VTE prophylaxis: Early(24 hours). Outcomes were deep venous thrombosis(DVT), pulmonary embolism(PE), unplanned return to operating room (OR), unplanned intensive care unit (ICU) admission, post-prophylaxis packed red blood cells (PRBC) transfusion, and mortality. Nine thousand two hundred and seventy-two patients were identified. Overall, median age was 41years, 71.5% were male, and median[IQR] injury severity score was 3[1–8]. 53% had second-degree burns, and 80% had less than 40% of total body surface area affected. Median time to thromboprophylaxis initiation was 11[6–20.6] hours. Overall VTE rate was 0.9% (DVT−0.7%, PE−0.2%). On univariable analysis, early prophylaxis group had lower rates of DVT(0.6% vs 1.1%, P = .025), and PE(0.1% vs 0.6%, P < .001). On multivariable regression, late prophylaxis was associated with 1.8 times higher odds of DVT (aOR = 1.8, 95% CI = 1.04–3.11, P = .03), 4.8 times higher odds of PE(aOR = 4.8, 95% CI = 1.9–11.9, P < .001), and 2 times higher odds of unplanned ICU admission(aOR = 2.1, 95% CI = 1.4–3.1, P < .001). Furthermore, early thromboprophylaxis was not associated with increased odds of post-prophylaxis PRBC transfusion(aOR = 1.1, 95% CI = 0.8–1.4, P = .4), and mortality(aOR = 0.68, 95% CI = 0.4–1.1, P = .13). Early VTE prophylaxis in burn patients is associated with decreased rates of DVT and PE, without increasing the risk of bleeding and mortality. VTE prophylaxis may be initiated within 24 hours of admission to reduce VTE in this high-risk patient population.
• 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
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  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.
• Culbert, M. H., Nelson, A., Obaid, O., Castanon, L., Hosseinpour, H., Anand, T., El-Qawaqzeh, K., Stewart, C., Reina, R., & Joseph, B. (2023). Failure-to-rescue and mortality after emergent pediatric trauma laparotomy: How are the children doing? “Pediatric Emergent Trauma Laparotomy”. Journal of Pediatric Surgery, 58(Issue 3). doi:10.1016/j.jpedsurg.2022.08.017
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  Introduction: Emergent trauma laparotomy is associated with mortality rates of up to 40%. There is a paucity of data on the outcomes of emergent trauma laparotomies performed in the pediatric population. The aim of our study was to describe the outcomes, including mortality and FTR, among pediatric trauma patients undergoing emergent laparotomy and identify factors associated with failure-to-rescue (FTR). Methods: We performed a one-year (2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program dataset. All pediatric trauma patients (age
• 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.
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  There is paucity of studies comparing the characteristics of trauma in geriatrics and super-geriatrics. We aimed to explore the injury characteristics and outcomes of older adult trauma patients on a nationwide scale.
• El-Qawaqzeh, K., 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
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  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.
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  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., 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(Issue 1). doi:10.1097/xcs.0000000000000716
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  BACKGROUND: 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. STUDY DESIGN: A 3-year analysis of the 2017 to 2019 American College of Surgeons TQIP. Adults (≥18 years) presenting after suicide attempts were included. Patients who died, those with emergency department discharge disposition, those with superficial lacerations, and those who were transferred to nonpsychiatric care facilities were excluded. Backward stepwise regression analyses were performed to identify predictors of receiving mental health services (inpatient psychiatric consultation/psychotherapy, discharge/transfer to a psychiatric hospital, or admission to a distinct psychiatric unit of a hospital). RESULTS: We identified 18,701 patients, and 56% received mental health services. The mean age was 40 ± 15 years, 72% were males, 73% were White, 57% had a preinjury psychiatric comorbidity, and 18% were uninsured. Of these 18,701 patients, 43% had moderate to severe injuries (Injury Severity Score > 8), and the most common injury was cut/stab (62%), followed by blunt mechanisms (falls, lying in front of a moving object, and intentional motor vehicle collisions) (18%) and firearm injuries (16%). On regression analyses, Black race, Hispanic ethnicity, male sex, younger age, and positive admission alcohol screen were associated with lower odds of receiving mental health services (p < 0.05). Increasing injury severity, being insured, having preinjury psychiatric diagnosis, and positive admission illicit drug screen were associated with higher odds of receiving mental health services (p < 0.05). CONCLUSIONS: Significant disparities exist in the management of survivors of suicide attempts. There is a desperate need for improved access to mental health services. Further studies should focus on delineating the cause of these disparities, identifying the barriers, and finding solutions.
• 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.
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  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., 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(Issue 6). doi:10.1111/jgs.18286
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  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.
• El-Qawaqzeh, K., Magnotti, L. J., Hosseinpour, H., Nelson, A., Spencer, A. L., Anand, T., Bhogadi, S. K., Alizai, Q., Ditillo, M., & Joseph, B. (2023). Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes?. Injury, 110972.
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  It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes.
• Hosseinpour, H., Anand, T., Bhogadi, S. K., Colosimo, C., El-Qawaqzeh, K., Spencer, A. L., Castanon, L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Emergency Department Shock Index Outperforms Prehospital and Delta Shock Indices in Predicting Outcomes of Trauma Patients. Journal of Surgical Research, 291(Issue). doi:10.1016/j.jss.2023.05.008
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  Introduction: 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. Methods: This was a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (2017-2018). We included adult (≥18 y) trauma patients and excluded patients who were transferred, had missing vital signs, and those with severe head injuries (Head-Abbreviated Injury Scale>3). Outcome measures were 24-h and in-hospital mortality, 24-h packed red blood cells transfusions, and intensive care unit and hospital length of stay. Predictive performances of these SIs were evaluated by the Area Under the Receiver Operating Characteristics for the entire study cohort and across all injury severities. Results: A total of 750,407 patients were identified. Meanstandard deviation age and lowest systolic blood pressure were 53 ± 21 y, and 81 ± 32 mmHg, respectively. Overall, 24-h and in-hospital mortality were 1.2% and 2.5%, respectively. On multivariable analysis, all three SIs were independently associated with higher rates of 24-h and in-hospital mortality, blood product requirements, intensive care unit and hospital length of stay (P < 0.001). ED SI was superior to prehospital and delta SIs (P < 0.001) for all outcomes. On subanalysis of patients with moderate injuries, severe injuries, and positive delta SI, the results remained the same. Conclusions: ED SI outperformed both prehospital and delta SIs across all injury severities. Trauma triage guidelines should prioritize ED SI in the risk stratification of trauma patients who may benefit from earlier and more intense trauma activations.
• Hosseinpour, H., Anand, T., Bhogadi, S. K., Colosimo, C., El-Qawaqzeh, K., Spencer, A. L., Castanon, L., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Emergency Department Shock Index Outperforms Prehospital and Delta Shock Indices in Predicting Outcomes of Trauma Patients. The Journal of surgical research, 291, 204-212.
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  Multiple shock indices (SIs), including prehospital, emergency department (ED), and delta (ED SI - Prehospital SI) have been developed to predict outcomes among trauma patients. This study aims to compare the predictive abilities of these SIs for outcomes of polytrauma patients on a national level.
• Hosseinpour, H., El-Qawaqzeh, K., Magnotti, L. J., Bhogadi, S. K., Ghneim, M., Nelson, A., Spencer, A. L., Colosimo, C., Anand, T., Ditillo, M., & Joseph, B. (2023). The unexpected paradox of geriatric traumatic brain injury outcomes: Uncovering racial and ethnic disparities. American Journal of Surgery, 226(Issue 2). doi:10.1016/j.amjsurg.2023.05.017
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  Background: 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. Methods: Analysis of 2017–2019 ACS-TQIP. Included severe TBI patients ≥65 years. Patients who died within 24 h were excluded. Outcomes included mortality, cerebral monitors use, complications, and discharge disposition. Results: We included 208,495 patients (White = 175,941; Black = 12,194) (Hispanic = 195,769; Non-Hispanic = 12,258). On multivariable regression, White race was associated with higher mortality (aOR = 1.26; p < 0.001) and SNF/rehab discharge (aOR = 1.11; p < 0.001) and less likely to be discharged home (aOR = 0.90; p < 0.001) or to undergo cerebral monitoring (aOR = 0.77; p < 0.001) compared to Black. Non-Hispanics had higher mortality (aOR = 1.15; p = 0.013), complications (aOR = 1.26; p < 0.001), and SNF/Rehab discharge (aOR = 1.43; p < 0.001) and less likely to be discharged home (aOR = 0.69; p < 0.001) or to undergo cerebral monitoring (aOR = 0.84; p = 0.018) compared to Hispanics. Uninsured Hispanics had the lowest odds of SNF/rehab discharge (aOR = 0.18; p < 0.001). Conclusions: This study highlights the significant racial and ethnic disparities in the outcomes of geriatric TBI patients. Further studies are needed to address the reason behind these disparities and identify potentially modifiable risk factors in the geriatric trauma population.
• Hosseinpour, H., El-Qawaqzeh, K., Magnotti, L. J., Bhogadi, S. K., Ghneim, M., Nelson, A., Spencer, A. L., Colosimo, C., Anand, T., Ditillo, M., & Joseph, B. (2023). The unexpected paradox of geriatric traumatic brain injury outcomes: Uncovering racial and ethnic disparities. American journal of surgery, 226(2), 271-277.
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  Healthcare disparities have always challenged surgical care in the US. We aimed to assess the influence of disparities on cerebral monitor placement and outcomes of geriatric TBI patients.
• Hosseinpour, H., Magnotti, L. J., Bhogadi, S. K., Anand, T., El-Qawaqzeh, K., Ditillo, M., Colosimo, C., Spencer, A., Nelson, A., & Joseph, B. (2023). Time to Whole Blood Transfusion in Hemorrhaging Civilian Trauma Patients: There Is Always Room for Improvement. Journal of the American College of Surgeons, 237(1), 24-34.
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  Whole blood (WB) is becoming the preferred product for the resuscitation of hemorrhaging trauma patients. However, there is a lack of data on the optimum timing of receiving WB. We aimed to assess the effect of time to WB transfusion on the outcomes of trauma patients.
• Hosseinpour, H., Magnotti, L. J., Bhogadi, S. K., 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(Issue 1). doi:10.1097/xcs.0000000000000715
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  BACKGROUND: 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. STUDY DESIGN: The American College of Surgeons TQIP 2017 to 2019 database was analyzed. Adult trauma patients who received at least 1 unit of WB within the first 2 hours of admission were included. Patients were stratified by time to first unit of WB transfusion (first 30 minutes, second 30 minutes, and second hour). Primary outcomes were 24-hour and in-hospital mortality, adjusting for potential confounders. RESULTS: A total of 1,952 patients were identified. Mean age and systolic blood pressure were 42 ± 18 years and 101 ± 35 mmHg, respectively. Median Injury Severity Score was 17 [10 to 26], and all groups had comparable injury severities (p = 0.27). Overall, 24-hour and in-hospital mortality rates were 14% and 19%, respectively. Transfusion of WB after 30 minutes was progressively associated with increased adjusted odds of 24-hour mortality (second 30 minutes: Adjusted odds ratio [aOR] 2.07, p = 0.015; second hour: AOR 2.39, p = 0.010) and in-hospital mortality (second 30 minutes: AOR 1.79, p = 0.025; second hour: AOR 1.98, p = 0.018). On subanalysis of patients with an admission shock index >1, every 30-minute delay in WB transfusion was associated with higher odds of 24-hour (aOR 1.23, p = 0.019) and in-hospital (aOR 1.18, p = 0.033) mortality. CONCLUSIONS: Every minute delay in WB transfusion is associated with a 2% increase in odds of 24-hour and in-hospital mortality among hemorrhaging trauma patients. WB should be readily available and easily accessible in the trauma bay for the early resuscitation of hemorrhaging 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. Journal of Trauma and Acute Care Surgery, 95(Issue 3). doi:10.1097/ta.0000000000003915
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  BACKGROUND 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. METHODS This is a 3-year (2017-2019) analysis of the American College of Surgeons Trauma Quality Improvement Program database. All children (younger than 15 years) who were transferred from other facilities to Level I or II PTC were included and stratified by level of receiving PTCs and injury severity. Outcome measures were in-hospital mortality and major complications. RESULTS A total of 67,726 transferred pediatric trauma patients were identified, of which 52,755 were transferred to Level I and 14,971 to Level II. The mean ± SD age and median Injury Severity Score were 7 ± 4 years and 4 (1-6), respectively. Eighty-five percent were transported by ground ambulance. The median transfer time for Levels I and II was 93 (70-129) and 90 (66-128) minutes, respectively (p < 0.001). On multivariable regression, interfacility transfers to Level I PTCs were associated with decreased risk-adjusted odds of in-hospital mortality among the mildly to moderately injured group (adjusted odds ratio, 0.59; p = 0.037) and severely injured group with a transfer time of less than 60 minutes (adjusted odds ratio, 0.27; p = 0.002). CONCLUSION Every minute increase in the interfacility transfer time is associated with a 2% increase in risk-adjusted odds of mortality among severely injured pediatric trauma patients. Factors other than the level of receiving PTCs, such as estimated transfer time and severity of injury, should be considered while deciding about transferring pediatric trauma patients to higher levels of care. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
• Hosseinpour, H., Magnotti, L. J., Bhogadi, S. K., Colosimo, C., El-Qawaqzeh, K., Spencer, A. L., Anand, T., Ditillo, M., Nelson, A., & Joseph, B. (2023). Interfacility transfer of pediatric trauma patients to higher levels of care: The effect of transfer time and level of receiving trauma center. The journal of trauma and acute care surgery, 95(3), 383-390.
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  Interfacility transfer of pediatric trauma patients to pediatric trauma centers (PTCs) after evaluation in nontertiary centers is associated with improved outcomes. We aimed to assess the outcomes of transferred pediatric patients based on their severity of the injury, transfer time, and level of receiving PTCs.
• Hosseinpour, H., Nelson, A., Bhogadi, S. K., Spencer, A. L., Alizai, Q., Colosimo, C., Anand, T., Ditillo, M., Magnotti, L. J., & Joseph, B. (2023). Delayed versus early hepatic resection among patients with severe traumatic liver injuries undergoing damage control laparotomy. American journal of surgery.
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  We aimed to assess the effect of time to hepatic resection on the outcomes of patients with high-grade liver injuries who underwent damage control laparotomy (DCL).
• Nelson, A. C., Bhogadi, S. K., Hosseinpour, H., Stewart, C., Anand, T., Spencer, A. L., Colosimo, C. D., Magnotti, L. J., & Joseph, B. (2023). There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis. Journal of the American College of Surgeons, 237(Issue 5). doi:10.1097/xcs.0000000000000790
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  BACKGROUND: Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP). STUDY DESIGN: Retrospective analysis of the Nationwide Readmissions Database (2017). All frail geriatric (65 years or older) patients with ABP were included. Patients were grouped by treatment at index admission: CCY vs NOM with endoscopic retrograde cholangiopancreatography. Propensity score matching was performed in a 1:2 ratio. Primary outcomes were 6-month readmissions, mortality, and length of stay. Secondary outcomes were 6-month failure of NOM defined as readmission for recurrent ABP, unplanned pancreas-related procedures, or unplanned CCY. Subanalysis was performed to compare outcomes of unplanned CCY vs early CCY. RESULTS: A total of 29,130 frail geriatric patients with ABP were identified and 7,941 were matched (CCY 5,294; NOM 2,647). Patients in the CCY group had lower 6-month rates of readmission for pancreas-related complications, unplanned readmissions for pancreas-related procedures, overall readmissions, and mortality, as well as fewer hospitalized days (p < 0.05). NOM failed in 12% of patients and 7% of NOM patients were readmitted within 6 months to undergo CCY, of which 56% were unplanned. Patients who underwent unplanned CCY had higher complication rates and hospital costs, longer hospital lengths of stay, and increased mortality compared with early CCY (p < 0.05). CONCLUSIONS: For frail geriatric patients with ABP, early CCY was associated with lower 6-month rates of complications, readmissions, mortality, and fewer hospitalized days. NOM was unsuccessful in nearly 1 of 7 within 6 months; of these, one-third required unplanned CCY. Early CCY should be prioritized for frail geriatric ABP patients when feasible. (J Am Coll Surg 2023;237:712–718.
• Nelson, A. C., Bhogadi, S. K., Hosseinpour, H., Stewart, C., Anand, T., Spencer, A. L., Colosimo, C., Magnotti, L. J., & Joseph, B. (2023). There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis. Journal of the American College of Surgeons, 237(5), 712-718.
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  Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP).
• Weaver, J. L., Cannada, L., Anand, T., Dream, S., Park, P. K., Altieri, M. S., Tasnim, S., & Reyna, C. (2023). The importance of allyship in Academic Surgery. American Journal of Surgery, 225(Issue 4). doi:10.1016/j.amjsurg.2022.10.058
• Weaver, J. L., Cannada, L., Anand, T., Dream, S., Park, P. K., Altieri, M. S., Tasnim, S., Reyna, C., & , A. o. (2023). The importance of allyship in Academic Surgery. American journal of surgery, 225(4), 805-807.
• Zambetti, B. R., Patel, D. D., Stuber, J. D., Zickler, W. P., Hosseinpour, H., Anand, T., Nelson, A. C., Stewart, C., Joseph, B., & Magnotti, L. J. (2023). Role of Endovascular Stenting in Patients with Traumatic Iliac Artery Injury. Journal of the American College of Surgeons, 236(4), 753-759.
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  Common and external iliac artery injuries (IAI) portend significant morbidity and mortality. The goal of this study was to examine the impact of mechanism of injury and type of repair on outcomes and identify the optimal repair for patients with traumatic IAI using a large, national dataset.
• Zambetti, B. R., Patel, D. D., Stuber, J. D., Zickler, W. P., Hosseinpour, H., Anand, T., Nelson, A. C., Stewart, C., Joseph, B., & Magnotti, L. J. (2023). Role of Endovascular Stenting in Patients with Traumatic Iliac Artery Injury. Journal of the American College of Surgeons, 236(Issue 4). doi:10.1097/xcs.0000000000000540
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  BACKGROUND: Common and external iliac artery injuries (IAI) portend significant morbidity and mortality. The goal of this study was to examine the impact of mechanism of injury and type of repair on outcomes and identify the optimal repair for patients with traumatic IAI using a large, national dataset. STUDY DESIGN: Patients undergoing operative repair for IAI were identified from the Trauma Quality Improvement Program database during a 5-year timespan, ending in 2019. Age, sex, race, severity of injury, severity of shock, type of iliac repair (open or endovascular), mechanism, morbidity and mortality were recorded. Patients with IAI were stratified by both type of repair and mechanism and compared. Multivariable logistic regression analysis was used to identify independent predictors of mortality. RESULTS: Operative IAI was identified in 507 patients. Of these injuries, 309 (61%) were penetrating and 346 (68.2%) involved the external iliac artery. The majority of patients were male (82%) with a median age and ISS of 31 and 20, respectively. Endovascular repair was performed in 31% of cases. For patients with penetrating injuries, the type of repair impacted neither morbidity nor mortality. For blunt-injured patients, endovascular repair was associated with lower morbidity (29.3% vs 41.3%; p = 0.082) and significantly reduced mortality (14.6% vs 26.7%; p = 0.037) compared with the open-repair approach. Multivariable logistic regression identified endovascular repair as the only modifiable risk factor associated with decreased mortality (odds ratio 0.34; 95% CI 0.15 to 0.79; p = 0.0116). CONCLUSIONS: Traumatic IAI causes significant morbidity and mortality. Endovascular repair was identified as the only modifiable predictor of decreased mortality in blunt-injured patients with traumatic IAI. Therefore, for select patients with blunt IAIs, an endovascular repair should be the preferred approach.
• 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, 57(Issue 12). doi:10.1016/j.jpedsurg.2022.07.005
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  Background: 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. Methods: We conducted a (2014–2016) retrospective analysis of the Trauma Quality Improvement Program. We selected all pediatric (age < 18) trauma patients who received at least one unit of packed red blood cells (PRBC) and fresh frozen plasma (FFP) within 4 h of admission. Patients were stratified based on their FFP:PRBC transfusion ratio in the first 4 h into: 1:1, 1:2, 1:3, and 1:3+. Primary outcomes were 24-mortality, in-hospital mortality. Secondary outcomes were complications and 24 h PRBC transfusion requirements. Multivariable logistic regression analysis was performed. Results: A total of 1,233 patients were identified of which 637 received transfusion ratio of 1:1, 365 1:2, 116 1:3, and 115 1:3+. Mean age was 11 ± 6y, 70% were male, ISS was 27 [20–38], and 62% sustained penetrating injuries. Patients in the 1:1 group had the lowest 24 h mortality (14% vs. 18% vs. 22% vs. 24%; p = 0.01) and in-hospital mortality (32% vs. 36% vs. 40% vs. 44%; p = 0.01). No difference was found between the groups in terms of complications (22% vs. 21% vs. 23% vs. 22%; p = 0.96) such as acute respiratory distress syndrome (3.3% vs. 3.6% vs. 0.9% vs. 0%; p = 0.10), and acute kidney injury (3% vs. 2.2% vs. 0.9% vs. 0.9%; p = 0.46). Additionally the 1:1 group had the lowest PRBC transfusion requirements (3[2–7] vs. 5[2–10] vs. 6[3–8] vs. 6[4–10]; p < 0.01). On regression analysis a progressive increase in the mortality adjusted odds ratio was observed as the FFP:PRBC transfusion ratio decreased. Conclusion: FFP:PRBC ratios closest to 1 were associated with increased survival in children. The resuscitation of pediatric patients should target a 1:1 ratio of FFP:PRBC. Further studies are needed for the development of massive transfusion protocols for this age group. Level of evidence: Level IV Study type: Therapeutic/Care Management
• 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.
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  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., Castanon, L., Ditillo, M., El-Qawaqzeh, K., Gries, L., Hosseinpour, H., Joseph, B., & Nelson, A. (2022). Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures. JAMA Surgery. doi:10.1001/jamasurg.2022.5772
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  Importance 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. Objective To characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures. Design, Setting, and Participants In this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021. Main Outcomes and Measures Primary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications. Results A total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P < .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P < .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications. Conclusions and Relevance This study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.
• Anand, T., Nelson, A. C., Obaid, O., Ditillo, M. F., El-Qawaqzeh, K. W., Stewart, C., Reina 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
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  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.
• 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.
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  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.
• Culbert, M. H., Nelson, A., Obaid, O., Castanon, L., Hosseinpour, H., Anand, T., El-Qawaqzeh, K., Stewart, C., Reina, R., & Joseph, B. (2022). Failure-to-rescue and mortality after emergent pediatric trauma laparotomy: How are the children doing?. Journal of pediatric surgery.
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  Emergent trauma laparotomy is associated with mortality rates of up to 40%. There is a paucity of data on the outcomes of emergent trauma laparotomies performed in the pediatric population. The aim of our study was to describe the outcomes, including mortality and FTR, among pediatric trauma patients undergoing emergent laparotomy and identify factors associated with failure-to-rescue (FTR).
• Ditillo, M., Tang, A., Saljuqi, T., Obaid, O., Nelson, A., Joseph, B., Hammad, A., Ditillo, M., Asmar, S., & Anand, T. (2022). Marijuana and thromboembolic events in geriatric trauma patients: The cannabinoids clots correlation!. American journal of surgery, 223(4), 798-803. doi:10.1016/j.amjsurg.2021.07.036
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  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.
• 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.
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  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?. JAMA Surgery. doi:10.1097/01.xcs.0000895276.04948.e7
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  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.
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  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.
• Hosseinpour, H., El-Qawaqzeh, K., Stewart, C., Akl, M. N., Anand, T., Culbert, M. H., Nelson, A., Bhogadi, S. K., & Joseph, B. (2022). Emergency readmissions following geriatric ground-level falls: How does frailty factor in? “Ground-Level Falls among Frail Patients”. Injury, 53(Issue 11). doi:10.1016/j.injury.2022.08.048
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  Background: Ground-level falls (GLFs) in older adults are increasing as life expectancy increases, and more patients are being discharged to skilled nursing facilities (SNFs) for continuity of care. However, GLF patients are not a homogenous cohort, and the role of frailty remains to be assessed. Thus, the aim of this study is to examine the impact of frailty on the in-hospital and 30-day outcomes of GLF patients. Materials and Methods: This is a cohort analysis from the Nationwide Readmissions Database 2017. Geriatric (age ≥65 years) trauma patients presenting following GLFs were identified and grouped based on their frailty status. The associations between frailty and 30-day mortality and emergency readmission were examined by multivariate regression analyses adjusting for patient demographics and injury characteristics. Results: A total of 100,850 geriatric GLF patients were identified (frail: 41% vs. non-frail: 59%). Frail GLF patients were younger (81[74–87] vs. 83[76–89] years; p
• Hosseinpour, H., El-Qawaqzeh, K., Stewart, C., Akl, M. N., Anand, T., Culbert, M. H., Nelson, A., Bhogadi, S. K., & Joseph, B. (2022). Emergency readmissions following geriatric ground-level falls: How does frailty factor in?. Injury, 53(11), 3723-3728.
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  Ground-level falls (GLFs) in older adults are increasing as life expectancy increases, and more patients are being discharged to skilled nursing facilities (SNFs) for continuity of care. However, GLF patients are not a homogenous cohort, and the role of frailty remains to be assessed. Thus, the aim of this study is to examine the impact of frailty on the in-hospital and 30-day outcomes of GLF patients.
• 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(Issue 3). doi:10.1097/sla.0000000000005548
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  Objective: 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. Methods: Retrospective analysis of 2017 to 2018 American College of Surgeons (ACS) Pediatric Trauma Quality Improvement Program (TQIP). All children presenting with suspected/confirmed child abuse and an abuse report filed were included. Patients with missing information regarding abuse interventions were excluded. Outcomes were abuse investigations initiated among those with abuse reports, and change of caregiver at discharge among survivors with an investigation initiated. Multivariable regression analyses were performed. Results: A total of 7774 child abuse victims with an abuse report were identified. The mean age was 5±5 years, 4221 (54%) patients were White, 2297 (30%) Black, 1543 (20%) Hispanic, and 5298 (68%) had government insurance. The most common mechanism was blunt (63%), followed by burns (10%) and penetrating (10%). The median Injury Severity Score was 5 (1-12). The most common form of abuse was physical (92%), followed by neglect (6%), sexual (3%), and psychological (0.1%). The most common perpetrator of abuse was a care provider/teacher (49.5%), followed by a member of the immediate family (30.5%), or a member of the extended/step/foster family (20.0%). Overall, 6377 (82%) abuse investigations were initiated for those with abuse reports. Of these, 1967 (33%) resulted in a change of caregiver. Black children were more likely to have abuse investigated, and Black and Hispanic children were more likely to experience change of caregiver after investigations, while privately insured children were less likely to experience both. Conclusions: Significant racial, ethnic, and socioeconomic disparities exist in the nationwide management of child abuse. Further studies are strongly warranted to understand contributing factors and possible strategies to address them. Level of Evidence: Level III - therapeutic/care management.
• 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.
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  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. T., Amos, J. D., Teichman, A., Whitmill, M. L., Anand, T., Hosseinpour, H., Burruss, S. K., Dunn, J. A., Najafi, K., Godat, L. N., Enniss, T. M., Shoultz, T. H., Egodage, T., Bongiovanni, T., Hazelton, J. P., Colling, K. P., Costantini, T. W., Stein, D. M., , Schroeppel, T. J., et al. (2022). Prospective Validation and Application of the Trauma Specific Frailty Index (TSFI): Results of an AAST Multi-Institutional Observational Trial. The journal of trauma and acute care surgery.
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  The Frailty Index is a known predictor of adverse outcomes in geriatric patients. Trauma Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients.
• 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.
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  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.
• Nguyen, L., Ditillo, M. F., Reina Limon, R. F., Anand, T., Hosseinpour, H., Nelson, A. C., 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
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  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.
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  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.
• Obaid, O., Nelson, A., Kitts, D. J., Kapadia, M., Joseph, B., Hammad, A., Douglas, M., Ditillo, M., & Anand, T. (2022). Evaluation of Frailty Assessment Compliance in Acute Care Surgery: Changing Trends, Lessons Learned.. The Journal of surgical research, 270, 236-244. doi:10.1016/j.jss.2021.09.019
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  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..We performed a 7-y (2011-2017) analysis of our prospectively maintained frailty database. Frail patients were identified using the emergency general surgery and trauma specific frailty indices. Outcome measures were rates of compliance with frailty assessment, overall complications, discharge to skilled nursing facility (SNF)/rehab, and mortality over the study period. Multivariate logistic regression and Cochran-Armitage trend analyses were performed..We evaluated a total of 1045 geriatric patients (Trauma: 587, EGS: 458). Mean age was 74.5 ± 7.9 y, 74% were males, and 81% were white. Overall, 34% of the patients were frail. Compared to non-frail patients, frail patients had higher adjusted rates of complications (OR 2.4 [1.9-2.9]), mortality (OR 1.8 [1.4-2.3]), and rehab/SNF disposition (OR 3.7 [3.1-4.3]). The compliance rate of measuring frailty increased from 12% in 2011 to 78% in 2017, P < 0.001 (Figure). The complication rate decreased (33% versus 21%, P < 0.001), while the rate of discharge disposition to SNF/Rehab increased (41% versus 58%, P < 0.001). There was no difference in mortality (11% versus 9.8%, P = 0.48) over the study period..Adherence to frailty measurement increased over the study period. This was accompanied by a significant decline in overall in-hospital complications. Frailty indices can be utilized to identify high-risk patients and develop post-operative strategies to improve outcomes in acute care surgery.
• Pretorius, D., Richter, R. P., Anand, T., Cardenas, J. C., & Richter, J. R. (2022). Alterations in heparan sulfate proteoglycan synthesis and sulfation and the impact on vascular endothelial function. Matrix biology plus, 16, 100121.
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  The glycocalyx attached to the apical surface of vascular endothelial cells is a rich network of proteoglycans, glycosaminoglycans, and glycoproteins with instrumental roles in vascular homeostasis. Given their molecular complexity and ability to interact with the intra- and extracellular environment, heparan sulfate proteoglycans uniquely contribute to the glycocalyx's role in regulating endothelial permeability, mechanosignaling, and ligand recognition by cognate cell surface receptors. Much attention has recently been devoted to the enzymatic shedding of heparan sulfate proteoglycans from the endothelial glycocalyx and its impact on vascular function. However, other molecular modifications to heparan sulfate proteoglycans are possible and may have equal or complementary clinical significance. In this narrative review, we focus on putative mechanisms driving non-proteolytic changes in heparan sulfate proteoglycan expression and alterations in the sulfation of heparan sulfate side chains within the endothelial glycocalyx. We then discuss how these specific changes to the endothelial glycocalyx impact endothelial cell function and highlight therapeutic strategies to target or potentially reverse these pathologic changes.
• 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, 224(Issue 5). doi:10.1016/j.amjsurg.2022.06.019
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  Background: This study aims to assess the impact of pre-injury anticoagulant use on outcomes of isolated blunt abdominal SOI patients who underwent NOM. Methods: A 1-year(2017) analysis of the ACS-TQIP. We included all ≥18yrs trauma patients with isolated blunt abdominal-SOI who underwent NOM. Patients were stratified into two groups based on their history of pre-injury anticoagulant use. Propensity score matching was performed. Results: A matched cohort of 2709 patients (AC, 903; No-AC,1806) was analyzed. Compared to the No-AC group, the AC group had higher rates of failure of NOM(2.6% vs. 4.5%, p = 0.03), cardiac arrest (1.2%vs. 3.1%, p = 0.02), acute kidney injury (2.4% vs. 4.2%, p < 0.01), myocardial infarction (0.6% vs. 1.4%,p = 0.03), and mortality (5.1%vs. 7.6%,p = 0.01), and longer hospital LOS (17[10–24]vs.17[12–26]days,p = 0.04) and ICU LOS (11[6–17]vs.11[7–18]days,p = 0.01). Conclusion: Among nonoperatively managed blunt abdominal SOI patients, preinjury use of anticoagulants negatively impacts outcomes. Extra surveillance is required while managing patients with blunt abdominal SOI on pre-injury anticoagulants. Level of evidence: Level III. Study type: Therapeutic/care management.
• 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.
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  This study aims to assess the impact of pre-injury anticoagulant use on outcomes of isolated blunt abdominal SOI patients who underwent NOM.
• Reina, R., Obaid, O., Nelson, A., Joseph, B., Gries, L., Douglas, M., Ditillo, M., Castanon, L., Bible, L., & Anand, T. (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, Publish Ahead of Print. doi:10.1097/ta.0000000000003574
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  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 is to examine the effect of these advancements on outcomes of blunt trauma patients undergoing emergency laparotomy..This is a 5-year (2013-2017) analysis of the Trauma Quality Improvement Program. Adult (age ≥ 18 years) blunt trauma patients with early (≤4 hours) PRBC and FFP transfusions and an emergency (≤4 hours) laparotomy for hemorrhage control were identified. Time-trend analysis of 24-hour mortality, PRBC/FFP ratio, and time to laparotomy was performed over the study period. The association between mortality and PRBC/FFP ratio, patient demographics, injury characteristics, transfusion volumes, and ACS verification level was examined by hierarchical regression analysis adjusting for inter-year variability..A total of 9,773 blunt trauma patients with emergency laparotomy were identified. Mean age was 44 ± 18 years, 67.5% were male, and median ISS was 34 [24-43]. Mean SBP at presentation was 73 ± 28 mm Hg, and median transfusion requirements were PRBC 9 [5-17] and FFP 6 [3-12]. During the 5-year analysis, time to laparotomy decreased from 1.87 hours to 1.37 hours (p < 0.001), PRBC/FFP ratio at 4 hours decreased from 1.93 to 1.71 (p < 0.001), and 24-hour mortality decreased from 23.0% to 19.3% (p = 0.014). (Figure) On multivariate analysis, decreased PRBC/FFP ratio was independently associated with decreased 24-hour mortality (OR 0.88; p < 0.001) and in-hospital mortality (OR 0.89; p < 0.001)..Resuscitation is becoming more balanced and time to emergency laparotomy shorter in blunt trauma patients, with a significant improvement in mortality. Future efforts should be directed towards incorporating transfusion practices and timely surgical interventions as markers of trauma center quality..Level III.
• Reina, R., Obaid, O., Northcutt, A., Nelson, A., Joseph, B., Gries, L., Ditillo, M., Castanon, L., Bible, L., & Anand, T. (2022). Prospective Validation of The Rib Injury Guidelines (RIG) For Traumatic Rib Fractures.. The journal of trauma and acute care surgery, Publish Ahead of Print. doi:10.1097/ta.0000000000003535
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  The Rib Injury Guidelines (RIG) were developed to guide triage of traumatic rib fracture patients to home, regular floor, or ICU and standardize care. The RIG score is based on patient history, physical examination, and imaging findings. The aim of this study is to evaluate triage effectiveness and healthcare resources utilization following RIG implementation..This is a prospective analysis at a Level I trauma center from October 2017 to January 2020. Adult (age ≥ 18 years) blunt trauma patients with a diagnosis of at least one rib fracture on CT imaging were included. Patients before (PRE) and after (POST) implementation of RIG were compared. In the POST group, patients were divided into RIG 1, RIG 2, and RIG 3 based on their RIG score. Outcomes were readmission for RIG 1 patients, unplanned ICU admission for RIG 2 patients, and overall ICU admission. Secondary outcomes were hospital length of stay (LOS) and mortality..A total of 1100 patients were identified (PRE: 754; POST: 346). Mean age was 56 ± 19 years, 788 (71.6%) were male, and median ISS was 14 [10-22]. The most common mechanism of injury was motor vehicle collision (554; 50.3%), 253 (22.9%) patients had ≥5 rib fractures, and 53 (4.8%) patients had a flail chest. In the POST group, 74 patients (21.1%) were RIG 1, 121 (35.2%) RIG 2, and 151 (43.7%) RIG 3. No patient in RIG 1 was readmitted following initial discharge, and 2 (1.6%) patients in RIG 2 had an unplanned ICU admission (both for alcohol withdrawal syndrome). POST patients had shorter hospital LOS (3 [1-6] vs. 4 [1-7] days; p = 0.019) and no difference in mortality (5.8% vs. 7.7%; p = 0.252). On multivariate analysis, RIG implementation was associated with decreased ICU admission (aOR 0.55 [0.36-0.82]; p = 0.004)..RIG is safe and effectively defines triage of rib fracture patients with an overall reduction in ICU admissions, shorter hospital LOS, and no readmissions..Level III.
• Sumra, H., Riner, A. N., Arjani, S., Tasnim, S., Zope, M., Reyna, C., & Anand, T. (2022). Minimizing implicit bias in search committees. American Journal of Surgery, 224(Issue 4). doi:10.1016/j.amjsurg.2022.05.014
• Sumra, H., Riner, A. N., Arjani, S., Tasnim, S., Zope, M., Reyna, C., & Anand, T. (2022). Minimizing implicit bias in search committees. American journal of surgery, 224(4), 1179-1181.
• Zope, M., Tasnim, S., Sumra, H., Riner, A. N., Reyna, C., Henry, M., Arjani, S., & Anand, T. (2022). It begins with the search committee: Promoting faculty diversity at the source.. American journal of surgery, 223(2), 432-435. doi:10.1016/j.amjsurg.2021.08.027
• 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(Issue 5). doi:10.1007/s00268-020-05918-z
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  Background: 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. Methods: We performed a 1-year (2017) analysis of TQIP including all geriatric (age ≥ 65 years) trauma patients. The frailty index was calculated using 11-variables and a cutoff limit of 0.27 was defined for frail status. Multivariate regression analysis was performed to control for demographics, insurance status, injury parameters, vital signs, and ICU and hospital length of stay. Results: We included 41,111 frail geriatric trauma patients. In terms of race, among frail geriatric trauma patients, 35,376 were Whites and 2916 were African Americans; in terms of ethnicity, 37,122 were Non-Hispanics and 2184 were Hispanics. On regression analysis, the White race was associated with higher odds of mortality (OR, 1.5; 95% CI, 1.2–2.0; p < 0.01) and in-hospital complications (OR, 1.4; 95% CI, 1.1–1.9; p < 0.01). White patients were more likely to be discharged to SNF (OR, 1.2; 95% CI, 1.1–1.4; p = 0.03) and less likely to be discharged home (p = 0.04) compared to African Americans. Non-Hispanics were more likely to be discharged to SNF (OR, 1.3; 95% CI, 1.1–1.5; p < 0.01) and less likely to be discharged home (p < 0.01) as compared to Hispanics. No significant difference in in-hospital mortality was seen between Hispanics and Non-Hispanics. Conclusion: Race and ethnicity influence outcomes in frail geriatric trauma patients. These disparities exist regardless of age, gender, injury severity, and insurance status. Further studies are needed to highlight disparities by race and ethnicity and to identify potentially modifiable risk factors in the geriatric trauma population.
• 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.
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  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.
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  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 is to examine the outcomes of WB transfusion as an adjunct to component therapy (CT) compared to CT only as early resuscitation for pediatric 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. Journal of Trauma and Acute Care Surgery, 91(Issue 4). doi:10.1097/ta.0000000000003306
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  BACKGROUND 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. METHODS Children aged 1 to 17 years, who were transfused within 4 hours of presentation, were identified in the Trauma Quality Improvement Program 2017 database. Patients were stratified into those receiving WB-CT versus CT alone. Propensity score matching in a 1:2 ratio was performed based on patient demographics, injury characteristics, hemorrhage control interventions, and trauma center level. The primary outcome measure was patient transfusion requirement. Secondary outcome measures were mortality, hospital length of stay, ventilation days, and major complications. RESULTS A total of 135 children receiving WB-CT were matched to 270 patients receiving CT only. Mean (SD) age was 12 (5) years, 66% were male, and the median Injury Severity Score was 32 (range, 20-43). A total of 51% of patients were in shock, 34% had penetrating injuries, and 41% required surgical intervention for hemorrhage control. Total blood products transfused were significantly decreased in children receiving WB, both at 4 hours (35 [22-73] vs. 48 [33-95] mL/kg; p = 0.013) and 24 hours (39 [24-97] vs. 53 [36-119] mL/kg; p < 0.001). Mortality rate at 24 hours (19.3% vs. 21.9%; p = 0.546) and in-hospital mortality (31.1% vs. 34.4%; p = 0.502) were not different. Similarly, no difference in hospital length of stay and rates of major complications was found. Patients in the WB group required significantly less ventilation days (2 [2-6] vs. 3 [2-8] days; p = 0.021). CONCLUSION Using WB as an adjunct to CT was associated with decreased transfusion requirements and ventilation days in pediatric trauma patients.
• Arjani, S., Tasnim, S., Sumra, H., Zope, M., Riner, A. N., Reyna, C., Henry, M., & Anand, T. (2021). It begins with the search committee: Promoting faculty diversity at the source. American journal of surgery.
• 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.
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  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., 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.
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  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).
• Bible, L., Anand, T., Obaid, O., Kitts, D. J., Khurrum, M., Kapadia, M., Joseph, B., Hammad, A., Goh, M., Bible, L., & Anand, T. (2021). Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes?. The Journal of surgical research, 268, 634-642. doi:10.1016/j.jss.2021.08.001
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  Opioids are commonly used as an analgesic agent in the prehospital setting. Current efforts to prevent and control prescription opioid overuse are focused on the in-hospital and post-discharge phases. The aim of our study was to assess the associations between pre-hospital opioids use and in-hospital outcomes among trauma patients..We performed a 2 year (2016-2017) retrospective analysis of our Level-I trauma center database. We included all adult trauma patients (age > 18y) who received pre-hospital opioids (Fentanyl (F) or Morphine-Sulfate (MS)). Outcome measures were emergency-department (ED) hypotension (SPB < 90 mmHg), ED intubation, prescription opioid medication upon discharge, and mortality. Multivariate logistic regression was performed..In total, 709 patients were included in the analysis. Cutoff values of 200 mcg F and 15 mg MS were significantly associated with adverse outcomes. Overall, the ED hypotension rate was 14.4%, ED intubation rate was 6%, and ED mortality rate was 3.1%. On regression analysis, higher dosages of both pre-hospital F and pre-hospital MS were independently associated with increased odds of ED hypotension, ED intubation, and discharge on opioid medications, but not with ED mortality..Pre-hospital administration of high dose opioids is associated with increased odds of adverse outcomes. Collaborative efforts to standardize and control the overuse of opioids should target the pre-hospital setting to limit opioid associated adverse effects.
• Bible, L., Obaid, O., Khurrum, M., Goh, M., Hammad, A., Kitts, D. J., Anand, T., Kapadia, M., & Joseph, B. (2021). Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes?. The Journal of surgical research, 268, 634-642.
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  Opioids are commonly used as an analgesic agent in the prehospital setting. Current efforts to prevent and control prescription opioid overuse are focused on the in-hospital and post-discharge phases. The aim of our study was to assess the associations between pre-hospital opioids use and in-hospital outcomes among trauma patients.
• 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.
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  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.
• 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.
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  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.
• 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.
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  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.
• 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. Journal of Surgical Research, 268(Issue). doi:10.1016/j.jss.2021.07.022
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  Introduction: 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. Methods: Adult (age ≥18 years) trauma patients presenting with TDI that required surgical repair were identified in the Trauma Quality Improvement Program database 2017. Patients were excluded if they underwent any other surgical procedure of the abdomen or chest. Patients were then stratified into 2 groups based on the surgical approach: laparoscopic repair of the diaphragm versus open repair. Propensity-score matching in a 1:2 ratio was performed. Primary outcome measures were in-hospital major complications and length of stay (LOS). Secondary outcome measure was in-hospital mortality. Results: A total of 177 adult trauma patients who had a laparoscopic repair of their isolated diaphragmatic injury were matched to 354 patients who had an open repair. Mean age was 35 ± 16 years, 78% were male, and mean BMI was 27 ± 7 kg/m2. 67 percent of the patients had penetrating injuries, and the median ISS was 17 [9-21]. CT imaging was done in 67% of the patients, with 71% presenting with left-sided injury and 21% having visceral herniation. Conversion from laparoscopic to open was reported in 7.3% of the cases. Patients with a laparoscopic repair had significantly lower rates of major complications (5.6 versus 14.4%; P
• 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.
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  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.
• Anand, T., Ditillo, M., Kulvatunyou, N., Tang, A. L., Saljuqi, A. T., Northcutt, A., Kulvatunyou, N., Joseph, B., Hamidi, M. K., Haddadin, Z., Gries, L. M., Ditillo, M., & Anand, T. (2019). Association of Racial, Ethnic Disparities, and Frailty in Geriatric Trauma Patients. Journal of The American College of Surgeons, 229(4), S119. doi:10.1016/j.jamcollsurg.2019.08.265
• Anand, T., Roller, L. K., & Jurkovich, G. J. (2019). Vitamin C in surgical sepsis. Current opinion in critical care, 25(6), 712-716.
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  The current review discusses the supplemental use of vitamin C as an adjunct in the management of sepsis and septic shock.
• Anand, T., Tang, A., Joseph, B., & Anand, T. (2019). Penetrating Neck Trauma: a Review. Current Trauma Reports, 5(1), 12-18. doi:10.1007/s40719-019-0154-6
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  This review focuses on the management of penetrating neck trauma and its evolution over the last several decades. Our increased experience with high-resolution computed tomography has changed the management of penetrating neck trauma from an anatomically zone-based approach to a “no zone” approach. Physical signs and symptoms of vascular, airway, and digestive track injuries still guide the basis of further radiographic and surgical workup. With the advancement and greater availability of multi-detector computed tomography (MDCT) technology, assessment of injuries has become easier and far more accurate. The hemodynamically stable patient may now be approached in a “no-zone” manner, and in certain cases managed safely with conservative measures. Wartime experience and improved technology played major roles in the evolution of penetrating neck injury management. Aggressive surgical exploration had given way to selective management based on anatomical neck zones, to most currently a “no zone” approach.
• Anand, T., & Skinner, R. (2018). Vitamin C in burns, sepsis, and trauma. The journal of trauma and acute care surgery, 85(4), 782-787.
• Anand, T., Ponce, S., Pakula, A., Norville, C., Kallish, D., Martin, M., & Skinner, R. (2018). Results from a Quality Improvement Project to Decrease Infection-Related Ventilator Events in Trauma Patients at a Community Teaching Hospital. The American surgeon, 84(10), 1701-1704.
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  Ventilator-associated pneumonia (VAP) is linked to increased morbidity and mortality and clinical protocols (VAP bundles) have evolved to minimize VAP. In 2009, a quality improvement project was implemented at our institution to decrease VAP rates in adult trauma patients. A VAP prevention committee was developed, and formal evidence-based education for the nursing and physician staff was introduced. During the study period (2009-2016), 2380 patients required ICU admission to our Level II trauma center. The mean Injury Severity Score was 33 + 12, and there were 17 per cent penetrating and 83 per cent blunt injuries. The early compliance (2010) with the VAP bundle was 65 per cent. Within one year of the implementation of VAP prevention, the compliance increased to >90 per cent. Compliance has been carefully trended and has remained at 100 per cent. All of the aforementioned interventions have resulted in a sustained dramatic decline in VAP, from 12 per cent in 2009 to 0 per cent in 2016. Ongoing education and ICU policy development has become the mainstay of our trauma ICU program. The introduction of evidence-based care education imparted a culture of excellence resulting in favorable outcomes in high-risk trauma patients related to VAP prevention. Ongoing monitoring and education is required to sustain these promising outcomes.
• Anand, T., Ponce, S., Pakula, A., Norville, C., Kallish, D., Martin, M., & Skinner, R. (2018). Results from a quality improvement project to decrease infection-related ventilator events in trauma patients at a community teaching hospital. American Surgeon, 84(Issue 10).
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  Ventilator-associated pneumonia (VAP) is linked to increased morbidity and mortality and clinical protocols (VAP bundles) have evolved to minimize VAP. In 2009, a quality improvement project was implemented at our institution to decrease VAP rates in adult trauma patients. A VAP prevention committee was developed, and formal evidence-based education for the nursing and physician staff was introduced. During the study period (2009-2016), 2380 patients required ICU admission to our Level II trauma center. The mean Injury Severity Score was 33 1 12, and there were 17 per cent penetrating and 83 per cent blunt injuries. The early compliance (2010) with the VAP bundle was 65 per cent. Within one year of the implementation of VAP prevention, the compliance increased to >90 per cent. Compliance has been carefully trended and has remained at 100 per cent. All of the aforementioned interventions have resulted in a sustained dramatic decline in VAP, from 12 per cent in 2009 to 0 per cent in 2016. Ongoing education and ICU policy development has become the mainstay of our trauma ICU program. The introduction of evidence-based care education imparted a culture of excellence resulting in favorable outcomes in high-risk trauma patients related to VAP prevention. Ongoing monitoring and education is required to sustain these promising outcomes.
• Anand, T., Ramnanan, R., Skinner, R., & Martin, M. (2016). Impact of Massive Transfusion and Aging Blood in Acute Trauma. The American surgeon, 82(10), 957-959.
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  Blood transfusions cause altered immunity and the duration of storage is contributory. In the era of massive transfusion protocols (MTPs) this impact is unclear, particularly as it relates to balanced transfusions. Trauma patients requiring our MTP after admission to our Level II trauma center were studied. The average age of blood transfused was calculated; old blood was a storage time of ≥14 days versus new blood 1:1. Infections, organ dysfunction multiorgan injury (MOI), and death were compared based on ratios and blood storage times. Of 2200 trauma admissions, 89 patients required MTP. Penetrating injuries were the majority, n = 53; and Injury Severity Score was 33 ± 14. Overall mortality was 31 per cent and sepsis was 28 per cent. Outcomes (storage time): Patients receiving old versus new blood had comparable age and Injury Severity Score. Sepsis rates, multiorgan injury and mortality were similar. Outcomes (packed red blood cells:fresh frozen plasma): Balanced transfusions (ratios of 1:1) demonstrated significant survival benefit and less infections compared with ratios >1:1. These data underscore the complexity of transfusion-related morbidity. In the modern era of MTP and balanced transfusions, the age of stored blood may not impact outcomes as demonstrated historically.
• Anand, T., Ramnanan, R., Skinner, R., & Martin, M. (2016). Impact of massive transfusion and aging blood in acute trauma. American Surgeon, 82(Issue 10).
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  Blood transfusions cause altered immunity and the duration of storage is contributory. In the era of massive transfusion protocols (MTPs) this impact is unclear, particularly as it relates to balanced transfusions. Trauma patients requiring our MTP after admission to our Level II trauma center were studied. The average age of blood transfused was calculated; old blood was a storage time of ≥14 days versus new blood 1:1. Infections, organ dysfunctionmultiorgan injury (MOI), and death were compared based on ratios and blood storage times. Of 2200 trauma admissions, 89 patients requiredMTP. Penetrating injuries were the majority, n 5 53; and Injury Severity Score was 33 ± 14. Overall mortality was 31 per cent and sepsis was 28 per cent. Outcomes (storage time): Patients receiving old versus new blood had comparable age and Injury Severity Score. Sepsis rates, multiorgan injury and mortality were similar. Outcomes (packed red blood cells:fresh frozen plasma): Balanced transfusions (ratios of 1:1) demonstrated significant survival benefit and less infections compared with ratios >1:1. These data underscore the complexity of transfusion-related morbidity. In the modern era of MTP and balanced transfusions, the age of stored blood may not impact outcomes as demonstrated historically.
• Anand, T., Vansonnenberg, E., Gadani, K., & Skinner, R. (2016). A snapshot of circulation failure following acute traumatic injury: The expansion of computed tomography beyond injury diagnosis. Injury, 47(Issue 1). doi:10.1016/j.injury.2015.09.013
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  Objective CT scans with a flat Inferior Vena Cava (IVC) suggest hypovolemia, and the presence of shock bowel implies hypoperfusion. The purpose of this study is to correlate injury severity, resuscitation needs, and clinical outcomes with CT indices of hypovolemia and hypoperfusion. Design Retrospective cohort study. Setting Level II trauma centre in Central California. Patients Adult patients imaged with abdominal and pelvic CT scans, from January 2010-January 2011. Interventions None. Measurements and main results Circulatory derangements on CT scans were defined as an IVC (AP) diameter measurement of
• Anand, T., vanSonnenberg, E., Gadani, K., & Skinner, R. (2016). A snapshot of circulation failure following acute traumatic injury: The expansion of computed tomography beyond injury diagnosis. Injury, 47(1), 50-2.
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  CT scans with a flat Inferior Vena Cava (IVC) suggest hypovolemia, and the presence of shock bowel implies hypoperfusion. The purpose of this study is to correlate injury severity, resuscitation needs, and clinical outcomes with CT indices of hypovolemia and hypoperfusion.
• Anand, T., Vansonnenberg, E., Gadani, K., & Skinner, R. (2013). 248: CT BEYOND TRAUMA DIAGNOSIS. Critical Care Medicine, 41, A56-A57. doi:10.1097/01.ccm.0000439395.65611.f8
• Anand, T., & Skinner, R. (2012). Arginine vasopressin: the future of pressure-support resuscitation in hemorrhagic shock. The Journal of surgical research, 178(1), 321-9.
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  Arginine vasopressin (AVP) is a key player in maintaining the intravascular volume and pressure during hemorrhagic shock. During the past 2 decades, animal studies, case reports, and reviews have documented the minimized blood loss and improved perfusion pressures in those receiving pressure support with AVP.

Proceedings Publications

• Hosseinpour, H., Magnotti, L. J., Huang, D. D., Weinberg, J. A., Tang, A., Hejazi, O., Stewart, C., Bhogadi, S. K., Anand, T., & Joseph, B. (2024). The role of number of affected vessels on radiologic and clinical outcomes of patients with blunt cerebrovascular injury. In american surgical conference, 80.
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  Objective: There is a lack of data on the role of characteristics of injured vessels on the outcomes of patients with blunt cerebrovascular injuries (BCVIs). The aim of this study was to assess the effect of the number (single vs multiple) of injured vessels on outcomes. Methods: This is a retrospective study at two American College of Surgeons Level I trauma centers (2017-2021). Adult (>16 years) trauma patients with BCVIs are included. Injuries were graded by the Denver Scale based on the initial computed tomography angiography (CTA). Early repeat CTA was performed 7 to 10 days after diagnosis. Patients were stratified by the number (single vs multiple) of the involved vessels. Outcomes included progression of BCVIs on repeat CTA, stroke, and in-hospital mortality attributable to BCVIs. Multivariable regression analyses were performed to identify the association between the number of injured vessels and outcomes. Results: A total of 491 patients with 591 injured vessels (285 carotid and 306 vertebral arteries) were identified. Sixty percent were male, the mean age was 44 years, and the median Injury Severity Score was 18 (interquartile range, 11-25). Overall, 18% had multiple-vessel injuries, 16% had bilateral vessel injuries, and 3% had multiple injuries on the same side. The overall rates of progression to higher-grade injuries, stroke, and mortality were 23%, 7.7%, and 8.8%, respectively. On uni- and multivariable analyses, multiple BCVIs were associated with progression to higher-grade injuries on repeat imaging, stroke, and mortality compared with single-vessel injuries. Conclusions: BCVIs with multiple injured vessels are more likely to progress to higher grades on repeat CTA, with multiple injuries independently associated with worse clinical outcomes, compared with those with single injuries. These findings highlight the importance of incorporating the number of injured vessels in clinical decision-making and in defining protocols for repeat imaging.
• Magnotti, L. J., Bhogadi, S. K., Anand, T., Stewart, C., Colosimo, C., Spencer, A. L., Nelson, A., & Joseph, B. (2024). Less Is More: Dissecting Trauma Centers by Procedural Volume. In american surgical association, 280.
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  Objective: This study aims to examine the relationship between procedural volume and annual trauma volume (ATV) of ACS Level I trauma centers (TC). Background: Although ATV is a hard criterion for TC verification, importance of procedural interventions as a potential quality indicator is understudied. Methods: Patients managed at ACS level I TCs were identified from ACS-TQIP 2017-2021. TCs were identified using facility keys and stratified into quartiles based on ATV into low, low-medium, medium-high, and high volume. TCs were also stratified into tertiles [low (LV), medium (MV), high (HV)] based on procedural volume by assessing annual number of laparotomies, thoracotomies, craniotomies/craniectomies, angioembolizations, vascular repairs, and long bone fixations performed at each center. The Cohen κ statistic was used to assess concordance between ATV and procedural volume. Results: A total of 182 Level I TCs were identified: 76 low, 47 low-medium, 35 high-medium, and 24 high volume. Long bone fixation, laparotomy, and craniotomy/craniectomy were the most performed procedures with a median of 65, 59, and 46 cases/center/year, respectively. Overall, 31% of HV laparotomy centers, 31% of HV thoracotomy centers, 22% of HV craniotomy/craniectomy centers, 22% of HV vascular repair centers, 32% of HV long bone fixation centers, and 33% of HV angioembolization centers contributed to the overall number of low-medium and low-volume TCs. The Cohen κ statistic demonstrated poor concordance between ATV and procedural volumes for all procedures (overall procedural volume - κ=0.378, laparotomy - κ=0.270, thoracotomy - κ=0.202, craniotomy/craniectomy - κ=0.394, vascular repair - κ=0.298, long bone fixation - κ=0.277, angioembolization - κ=0.286). Conclusions: ATV does not reflect the procedural interventions performed. Combination of procedural and ATV may provide a more accurate picture of the clinical experience at any given TC. Level of Evidence: Level III.
• 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 Western Trauma Association.
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  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.
• Joseph, B., Saljuqi, A., Amos, J., Teichman, A., Whitmill, M., Anand, T., Hosseinpour, H., Burruss, S., Dunn, J., Najafi, K., Godat, L., Enniss, T., Shoultz, T., Egodage, T., Bongiovanni, T., Hazelton, J., Colling, K., Costantini, T., Stein, D., , Thomas, J., et al. (2023). Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial. In AAST.
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  BACKGROUND: The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients. METHODS: This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13–0.25), and frail (TSFI, >0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission. RESULTS: A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5–13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p < 0.001), and discharge to rehab/SNFs (aOR, 1.98; p < 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge (p < 0.05). CONCLUSION: External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge.
• Joseph, B., Obaid, O., Dultz, L., Black, G., Campbell, M., Berndtson, A., Costantini, T., Kerwin, A., Skarupa, D., Burruss, S., Delgado, L., Gomez, M., Mederos, D., Winfield, R., Cullinane, D., Chehab, M., Anand, T., Nelson, A., Kim, S., & Luo-Owen, X. (2022). Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. In AAST.
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  INTRODUCTION Brain Injury Guidelines (BIG) was developed to effectively use health care resources including repeat head computed tomography (RHCT) scan and neurosurgical consultation in traumatic brain injury (TBI) patients. The aim of this study was to prospectively validate BIG at a multi-institutional level. METHODS This is a prospective, observational, multi-institutional trial across nine Levels I and II trauma centers. Adult (16 years or older) blunt TBI patients with a positive initial head computed tomography (CT) scan were identified and categorized into BIG 1, 2, and 3 based on their neurologic examination, alcohol intoxication, antiplatelet/anticoagulant use, and head CT scan findings. The primary outcome was neurosurgical intervention. The secondary outcomes were neurologic worsening, RHCT progression, postdischarge emergency department visit, and 30-day readmission. RESULTS A total of 2,432 patients met the inclusion criteria, of which 2,033 had no missing information and were categorized into BIG 1 (301 [14.8%]), BIG 2 (295 [14.5%]), and BIG 3 (1,437 [70.7%]). In BIG 1, no patient worsened clinically, 4 of 301 patients (1.3%) had progression on RHCT with no change in management, and none required neurosurgical intervention. In BIG 2, 2 of 295 patients (0.7%) worsened clinically, and 21 of 295 patients (7.1%) had progression on RHCT. Overall, 7 of 295 patients (2.4%) would have required upgrade from BIG 2 to 3 because of neurologic examination worsening or progression on RHCT, but no patient required neurosurgical intervention. There were no TBI-related postdischarge emergency department visits or 30-day readmissions in BIG 1 and 2 patients. All patients who required neurosurgical intervention were BIG 3 (280 of 1,437 patients [19.5%]). Agreement between assigned and final BIG categories was excellent (κ = 99%). In this cohort, implementing BIG would have decreased CT scan utilization and neurosurgical consultation by 29% overall, with a 100% reduction in BIG 1 patients and a 98% reduction in BIG 2 patients. CONCLUSION Brain Injury Guidelines is safe and defines the management of TBI patients by trauma and acute care surgeons without the routine need for RHCT and neurosurgical consultation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
• 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?. In N/A, 93.
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  BACKGROUND 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. METHODS We performed a 2-year (2016-2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program database. All adult trauma patients (≥18 years) who received FC or Cryo as an adjunct to resuscitation were included. Patients with bleeding disorders, chronic liver disease, and those on preinjury anticoagulants were excluded. Patients were stratified into those who received FC, and those who received Cryo. Propensity score matching (1:2) was performed. Outcome measures were transfusion requirements, major complications, hospital, and intensive care unit lengths of stay, and mortality. RESULTS A matched cohort of 255 patients who received fibrinogen supplementation (85 in FC, 170 in Cryo) was analyzed. Overall, the mean age was 41 ± 19 years, 74% were male, 74% were white and median Injury Severity Score was 26 (22-30). Compared with the Cryo group, the FC group required less units of packed red blood cells, fresh frozen plasma, and platelets, and had shorter in-hospital and intensive care unit length of stay. There were no significant differences between the two groups in terms of major in-hospital complications and mortality. CONCLUSION Fibrinogen supplementation in the form of FC for the traumatic hemorrhagic patient is associated with improved outcomes and reduced transfusion requirements as compared with Cryo. Further studies are required to evaluate the optimal method of fibrinogen supplementation in the resuscitation of trauma patients. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
• 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?. In n/a, 91.
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  INTRODUCTION 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. METHODS We conducted a 2017 analysis of the Nationwide Readmissions Database and included frail geriatric (≥65 years) patients with ACC. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing cholecystectomy at index admission (operative management [OP]) versus those managed with nonoperative intervention (nonoperative management [NOP]). The NOP group was further subdivided into those who received antibiotics only and those who received percutaneous drainage. Primary outcomes were procedure-related complications in the OP group and 6-month failure of NOP (readmission with cholecystitis). Secondary outcomes were mortality and overall hospital length of stay. RESULTS A total of 53,412 geriatric patients with ACC were identified, 51.0% of whom were frail: 16,791 (61.6%) in OP group and 10,472 (38.4%) in NOP group (3,256 had percutaneous drainage, 7,216 received antibiotics only). Patients were comparable in age (76 ± 7 vs. 77 ± 8 years; p = 0.082) and modified frailty index (0.47 vs. 0.48; p = 0.132). Procedure-related complications in the OP group were 9.3%, and 6-month failure of NOP was 18.9%. Median time to failure of NOP management was 36 days (range, 12-78 days). Mortality was higher in the frail NOP group (5.2 vs. 3.2%; p < 0.001). The NOP group had more days of hospitalization (8 [4-15] vs. 5 [3-10]; p < 0.001). Both receiving antibiotics only (odds ratio, 1.6 [1.3-2.0]; p < 0.001) and receiving percutaneous drainage (odds ratio, 1.9 [1.7-2.2]; p < 0.001) were independently associated with increased mortality. CONCLUSION One in five patients failed NOP and subsequently had complicated hospital stays. Nonoperative management of frail elderly ACC patients may be associated with significant morbidity and mortality.
• 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. In asc, 91.
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  BACKGROUND 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. METHODS Adult (≥18 years) trauma patients receiving early (≤4 hours) plasma transfusions were identified in the Trauma Quality Improvement Program 2017. Patients were stratified into those receiving LQP versus FFP. Propensity-score matching in a 1:2 ratio was performed. Primary outcome measures were mortality and time to first plasma unit transfusion. Secondary outcome measures were major complications and hospital length of stay. RESULTS A total of 107 adult trauma patients receiving LQP were matched to 214 patients receiving FFP. Mean age was 48 ± 19 years, 73% were male, and median Injury Severity Score was 27 [23-41]. A total of 42% of patients were in shock, 22% had penetrating injuries, and 31% required surgical intervention for hemorrhage control. Patients received a median of 4 [2-6] units of PRBC, 2 [1,3] units of LQP or FFP, and 1 [0-1] unit of platelets. The median time to the first LQP unit transfused was significantly shorter compared with the first FFP unit transfused (54 [28-79] minutes vs. 98 [59-133] minutes; p < 0.001). Rates of 24-hour mortality (2.8% vs. 3.7%; p = 0.664) and in-hospital mortality (16.8% vs. 20.1%; p = 0.481) were not different between the LQP and FFP groups. Similarly, there was no difference in major complications (15.9% vs. 21.5%; p = 0.233) and hospital length of stay (12 [6-21] vs. 12 [6-23] days; p = 0.826). CONCLUSION Never-frozen liquid plasma is safe and effective in resuscitating trauma patients. Never-frozen liquid plasma has the potential to expand our transfusion armamentarium given its longer storage time and immediate availability. LEVEL OF EVIDENCE Therapeutic, Level IV.
• 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?. In n/a, 91.
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  BACKGROUND 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. METHODS We performed a 3-year (2015-2017) analysis of the American College of Surgeons-Trauma Quality Improvement Program database. All adult (age, ≥18 years) trauma patients who received WB were included. We excluded patients who were on preinjury anticoagulants. Patients were stratified into two groups, 4-PCC-WB versus WB alone, and matched in a 1:2 ratio using propensity score matching. Outcome measures were packed red blood cells, plasma, platelets, and cryoprecipitate transfused, in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS) among survivors, and mortality. RESULTS A total of 252 patients (4-PCC-WB, 84; WB alone, 168) were matched. The mean ± SD age was 47 ± 21 years, 63% were males, median Injury Severity Score was 30 (21-40), and 87% had blunt injuries. Patients who received 4-PCC-WB had decreased requirement for packed red blood cell (8 U vs. 10 U, p = 0.04) and fresh frozen plasma (6 U vs. 8 U, p = 0.01) transfusion, lower rates of acute kidney injury (p = 0.03), and ICU LOS (5 days vs. 8 days, p = 0.01) compared with WB alone. There was no difference in the platelet transfusion (p = 0.19), cryoprecipitate transfusion (p = 0.37), hospital LOS (p = 0.72), and in-hospital mortality (p = 0.72) between the two groups. CONCLUSION Our study demonstrates that the use of 4-PCC as an adjunct to WB is associated with a reduction in transfusion requirements and ICU LOS compared with WB alone in the resuscitation of trauma patients. Further studies are required to evaluate the role of PCC with WB in the resuscitation of trauma patients.
• 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. In AAST, 89.
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  BACKGROUND 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. METHODS We performed a 5-year (2010-2014) analysis of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age, ≥18 years) trauma patients who had traumatic CSCI and received tracheostomy. Patients were subdivided into two groups: early tracheostomy (ET) (≤4 days from initial intubation) and late tracheostomy (LT) (>4 days). Outcome measures included respiratory complications, ventilator-free days, intensive care unit-free days and hospital length of stay, and mortality. Multivariate logistic regression analysis was performed. RESULTS A total of 5,980 patients were included in the study, of which 1,010 (17%) patients received ET, while 4,970 (83%) patients received LT. Mean age was 46 years, and 73% were men. In terms of CSCI location, 48% of the patients had high CSCI (C1-C4), while 52% had low CSCI (C5-C7). Patients in the ET group had lower rates of respiratory complications (30% vs. 46%, p = 0.01), higher ventilator-free days (13 days vs. 9 days; p = 0.02), intensive care unit-free days (11 days vs. 8 days; p = 0.01), and a shorter hospital length of stay (22 days vs. 29 days; p = 0.01) compared with those in the LT group. On regression analysis, ET was associated with lower rates of respiratory complications in patients with high CSCI (odds ratio, 0.55 [0.41-0.81]) and low CSCI (odds ratio, 0.93 [0.72-0.95]). However, no association was found between time to tracheostomy and in-hospital mortality. CONCLUSION Early tracheostomy regardless of CSCI level may lead to improved outcomes. Quality improvement efforts should focus on defining the optimal time to tracheostomy and considering ET as a component of SCI management bundle. LEVEL OF EVIDENCE Therapeutic, level IV.

Presentations

• Anand, T., Fox, K., Joseph, B. A., Saha, S., Kim, M., & Suri, Y. (2022, November). The Implementation and Evaluation of a Surgical Learning Module and the Near-Peer Learning Model. Academic Surgical Congress. Washington, DC: Association for Academic Surgery.

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).
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  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.

Others

• Anand, T. (2024, September). Pediatrics and Injury Prevention
  Poster Professor. AAST.