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Background: Opioid overprescription in trauma contributes to the opioid epidemic through diversion of unused pills. Through our study, we sought to do the following: (1) understand the variation in opioid prescription after injury and its relationship to patient and/or clinical variables, and (2) study the relationship between opioid prescribing and long-term pain and analgesic use., Method: Trauma patients with an injury severity score ≥9 admitted to 3 level 1 trauma centers were screened for chronic pain and analgesic use 6 to 12 months postinjury. First, multivariable linear regression models were constructed with "oral morphine equivalents" and "number of opioid pills prescribed" at discharge as dependent variables. The coefficients of determination were calculated to determine how much of the variation in opioid prescription was explained by patient and clinical variables. Second, a multivariable logistic regression analysis was created to study the association between opioid prescription at discharge and chronic pain/analgesic use at 6 to 12 months. Analyses were adjusted for patient demographics, socioeconomics, comorbidities, injury parameters, and hospital course., Results: Of the 2,702 patients included (mean [standard deviation] age: 61.0 [21.5]; 55% males), 74% were prescribed opioids at discharge (mean number of pills [standard deviation]: 24.0 [26.5]; mean oral morphine equivalent [standard deviation]: 204.8 [348.1]). The adjusted coefficients of determination for oral morphine equivalents and number of pills was 0.12 and 0.21, respectively, suggesting that the measured patient and clinical factors explain <21% of the variation in opioid prescribing in trauma. Patients prescribed opioids were more likely to have chronic pain (odds ratio [95%] confidence interval: 1.34 [1.05-1.71]) and use analgesics daily (odds ratio [95%] confidence interval: 1.86 [1.25-2.77]) 6 to 12 months postinjury., Conclusion: The variation in opioid prescription after traumatic injury is more affected by system and provider level rather than clinical or patient-related factors, and opioid prescribing correlates independently with long-term chronic pain and continued analgesic use postinjury. Efforts to decrease opioid use should prioritize standardizing prescription practices after traumatic injury., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: International Classification of Disease, ninth/tenth revision codes are used to identify patients with appendicitis and classify severity of disease for research and hospital reimbursement. We sought to determine accuracy of International Classification of Disease, ninth/tenth revision codes in classifying appendicitis as uncomplicated versus complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report., Methods: Retrospective review of operative reports and discharge International Classification of Disease, ninth/tenth revision codes for patients ≥18 years old who underwent noninterval, nonincidental appendectomy between January 2012 and December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for International Classification of Disease, ninth/tenth revision codes to classify appendicitis accurately as complicated compared with surgeon description. ICD-9/10 codes and surgeon description were categorized into complicated/uncomplicated based on the American Association for the Surgery of Trauma grading system., Results: In the study, 1,495 patients with acute appendicitis underwent appendectomy. Per surgeon description, 200 (13%) were complicated and 1,295 (87%) uncomplicated. Compared with surgeon description, discharge International Classification of Disease, ninth/tenth revision codes did not accurately identify complicated appendicitis: sensitivity = 0.68, positive predictive value = 0.77. As a sensitivity analysis, the cohort was stratified by public versus private payers, and the results did not change., Conclusion: International Classification of Disease, ninth/tenth revision codes do not accurately identify surgeon-described complicated appendicitis. Nearly one-third of the cases of complicated appendicitis were coded as uncomplicated. Such misclassification negatively impacts reimbursement for complicated appendicitis care and could lead to misleading results in research and quality improvement activities that rely on these codes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate the Social Vulnerability Index (SVI) as a predictor of long-term outcomes after injury., Background: The SVI is a measure used in emergency preparedness to identify need for resources in the event of a disaster or hazardous event, ranking each census tract on 15 demographic/social factors., Methods: Moderate-severely injured adult patients treated at 1 of 3 level-1 trauma centers were prospectively followed 6 to 14 months post-injury. These data were matched at the census tract level with overall SVI percentile rankings. Patients were stratified based on SVI quartiles, with the lowest quartile designated as low SVI, the middle 2 quartiles as average SVI, and the highest quartile as high SVI. Multivariable adjusted regression models were used to assess whether SVI was associated with long-term outcomes after injury., Results: A total of 3153 patients were included [54% male, mean age 61.6 (SD = 21.6)]. The median overall SVI percentile rank was 35th (IQR: 16th-65th). compared to low SVI patients, high SVI patients were more likely to have new functional limitations [odds ratio (OR), 1.51; 95% confidence interval (CI), 1.19-1.92), to not have returned to work (OR, 2.01; 95% CI, 1.40-2.89), and to screen positive for post-traumatic stress disorder (OR, 1.56; 95% CI, 1.12-2.17). Similar results were obtained when comparing average with low SVI patients, with average SVI patients having significantly worse outcomes., Conclusions: The SVI has potential utility in predicting individuals at higher risk for adverse long-term outcomes after injury. This measure may be a useful needs assessment tool for clinicians and researchers in identifying communities that may benefit most from targeted prevention and intervention efforts., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: For adults with appendicitis, several randomized clinical trials have demonstrated that antibiotics are an effective alternative to appendectomy. However, it remains unknown how the characteristics of patients in such trials compare with those of patients who select their treatment and whether outcomes differ., Objective: To compare participants in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial (RCT) with a parallel cohort study of participants who declined randomization and self-selected treatment., Design, Setting, and Participants: The CODA trial was conducted in 25 US medical centers. Participants were enrolled between May 3, 2016, and February 5, 2020; all participants were eligible for at least 1 year of follow-up, with all follow-up ending in 2021. The randomized cohort included 1094 adults with appendicitis; the self-selection cohort included patients who declined participation in the randomized group, of whom 253 selected appendectomy and 257 selected antibiotics. In this secondary analysis, characteristics and outcomes in both self-selection and randomized cohorts are described with an exploratory analysis of cohort status and receipt of appendectomy., Interventions: Appendectomy vs antibiotics., Main Outcomes and Measures: Characteristics among participants randomized to either appendectomy or antibiotics were compared with those of participants who selected their own treatment., Results: Clinical characteristics were similar across the self-selection cohort (510 patients; mean age, 35.8 years [95% CI, 34.5-37.1]; 218 female [43%; 95% CI, 39%-47%]) and the randomized group (1094 patients; mean age, 38.2 years [95% CI, 37.4-39.0]; 386 female [35%; 95% CI, 33%-38%]). Compared with the randomized group, those in the self-selection cohort were less often Spanish speaking (n = 99 [19%; 95% CI, 16%-23%] vs n = 336 [31%; 95% CI, 28%-34%]), reported more formal education (some college or more, n = 355 [72%; 95% CI, 68%-76%] vs n = 674 [63%; 95% CI, 60%-65%]), and more often had commercial insurance (n = 259 [53%; 95% CI, 48%-57%] vs n = 486 [45%; 95% CI, 42%-48%]). Most outcomes were similar between the self-selection and randomized cohorts. The number of patients undergoing appendectomy by 30 days was 38 (15.3%; 95% CI, 10.7%-19.7%) among those selecting antibiotics and 155 (19.2%; 95% CI, 15.9%-22.5%) in those who were randomized to antibiotics (difference, 3.9%; 95% CI, -1.7% to 9.5%). Differences in the rate of appendectomy were primarily observed in the non-appendicolith subgroup., Conclusions and Relevance: This secondary analysis of the CODA RCT found substantially similar outcomes across the randomized and self-selection cohorts, suggesting that the randomized trial results are generalizable to the community at large., Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Background: Firearm injury remains a major cause of morbidity and mortality in the United States. Because of prior lack of comprehensive data sources, there is a paucity of literature on nonfatal firearm injury. Associations have previously been shown between state-level firearm laws and firearm fatalities, but few studies have examined the effects of these laws on nonfatal firearm hospitalization rates. Our objective was to examine the relationship between state firearm laws and firearm injury-related hospitalization rates across all 50 states over a 17-year period., Methods: In this panel study design, we used fixed effects multivariate regression models to analyze the relationship between 12 laws and firearm state-level injury-related hospitalization rates from 2000 to 2016 using the RAND Corporation Inpatient Hospitalizations for Firearm Injury Database. We used difference-in-differences to determine the impact of law passage in a given state compared with those states without the law, controlling for state-level covariates. The main outcome measure was the change in annual firearm injury-related inpatient hospitalization rates after passage or repeal of a state-level firearm law., Results: Examining each law individually, passage of violent misdemeanor, permitting, firearm removal from domestic violence offenders, and 10-round limit laws were associated with significant firearm injury-related hospitalization rate reductions. Examining multiple laws in the same model, passage of violent misdemeanor laws was associated with a 19.9% (confidence interval, 11.6%-27.4%) reduction, and removal of firearms from domestic violence offenders was associated with a 17.0% (confidence interval, 9.9%-23.6%) reduction in hospitalization rates., Conclusion: State laws related to preventing violent offenders from possessing firearms are associated with firearm injury-related hospitalization rate reductions. Given significant physical, mental, and social burdens of nonfatal firearm injury, determining the efficacy of firearm-related policy is critical to violence and injury prevention efforts., Level of Evidence: Prognostic and Epidemiologic; Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Determine the proportion and characteristics of traumatic injury survivors who perceive a negative impact of the COVID-19 pandemic on their recovery and to define post-injury outcomes for this cohort., Background: The COVID-19 pandemic has precipitated physical, psychological, and social stressors that may create a uniquely difficult recovery and reintegration environment for injured patients., Methods: Adult (≥18 years) survivors of moderate-to-severe injury completed a survey 6 to 14 months post-injury during the COVID-19 pandemic. This survey queried individuals about the perceived impact of the COVID-19 pandemic on injury recovery and assessed post-injury functional and mental health outcomes. Regression models were built to identify factors associated with a perceived negative impact of the pandemic on injury recovery, and to define the relationship between these perceptions and long-term outcomes., Results: Of 597 eligible trauma survivors who were contacted, 403 (67.5%) completed the survey. Twenty-nine percent reported that the COVID-19 pandemic negatively impacted their recovery and 24% reported difficulty accessing needed healthcare. Younger age, lower perceived-socioeconomic status, extremity injury, and prior psychiatric illness were independently associated with negative perceived impact of the COVID-19 pandemic on injury recovery. In adjusted analyses, patients who reported a negative impact of the pandemic on their recovery were more likely to have new functional limitations, daily pain, lower physical and mental component scores of the Short-Form-12 and to screen positive for PTSD and depression., Conclusions: The COVID-19 pandemic is negatively impacting the recovery of trauma survivors. It is essential that we recognize the impact of the pandemic on injured patients while focusing on directed efforts to improve the long-term outcomes of this already at-risk population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Assess the prevalence of anxiety, depression, and posttraumatic stress disorder (PTSD) after injury and their association with long-term functional outcomes., Background: Mental health disorders (MHD) after injury have been associated with worse long-term outcomes. However, prior studies almost exclusively focused on PTSD., Methods: Trauma patients with an injury severity score ≥9 treated at 3 Level-I trauma centers were contacted 6-12 months post-injury to screen for anxiety (generalized anxiety disorder-7), depression (patient health questionnaire-8), PTSD (8Q-PCL-5), pain, and functional outcomes (trauma quality of life instrument, and short-form health survey)). Associations between mental and physical outcomes were established using adjusted multivariable logistic regression models., Results: Of the 531 patients followed, 108 (20%) screened positive for any MHD: of those who screened positive for PTSD (7.9%, N = 42), all had co-morbid depression and/or anxiety. In contrast, 66 patients (12.4%) screened negative for PTSD but positive for depression and/or anxiety. Compared to patients with no MHD, patients who screened positive for PTSD were more likely to have chronic pain {odds ratio (OR): 8.79 [95% confidence interval (CI): 3.21, 24.08]}, functional limitations [OR: 7.99 (95% CI: 3.50, 18.25)] and reduced physical health [β: -9.3 (95% CI: -13.2, -5.3)]. Similarly, patients who screened positive for depression/anxiety (without PTSD) were more likely to have chronic pain [OR: 5.06 (95% CI: 2.49, 10.46)], functional limitations [OR: 2.20 (95% CI: 1.12, 4.32)] and reduced physical health [β: -5.1 (95% CI: -8.2, -2.0)] compared to those with no MHD., Conclusions: The mental health burden after injury is significant and not limited to PTSD. Distinguishing among MHD and identifying symptom-clusters that overlap among these diagnoses, may help stratify risk of poor outcomes, and provide opportunities for more focused screening and treatment interventions., Competing Interests: The authors report no conflict of interests., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Many medical students hold negative perceptions about the surgical field that deter them from pursuing surgical training. We hypothesize that these perceptions can be sustainably changed with preclinical surgical education., Design: Students were administered a 10-question survey before the educational experience, immediately after completing the experience, and 1-3 years later. Survey questions focused on perceptions about surgery. Changes in responses over time were measured and analyzed., Setting: The study was performed in the setting of a voluntary preclinical surgical education experience., Participants: Surveys were administered to 217 first-year medical students who all participated in the preclinical surgical education experience from 2017 to 2019. Follow-up surveys were administered to all cohorts simultaneously and anonymously via email., Results: Nine of the ten questions demonstrated statistically significant changes in perceptions from pre-experience to immediately post-experience (p < 0.048). Though attenuation was seen over time, changes in perception regarding the workload and time investment of surgical training, the role of women in surgery, and the relationships between surgeons and their patients were sustained over time (p < 0.044)., Conclusions: The results indicated that our model of surgical education could effect long-term changes in negative perceptions about the surgical field. Many of these negative perceptions are highly concerning to medical students. As such, success in changing perceptions about length and difficulty of training, gender inclusivity, and patient-centered care in surgery is important in increasing student interest in the surgical field. This becomes relevant in the current climate of a nationwide shortage of surgeons and the need to better attract students to this profession., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity., Methods: The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019-March 10, 2020 versus March 11, 2020-May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression., Results: There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 [0.51, 0.98]) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 [95% confidence interval 0.47-0.91]) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 [95% confidence interval 0.52-1.52]); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 [95% confidence interval 0.83-2.25])., Conclusion: The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care-use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease., (Published by Elsevier Inc.)

Introduction: Psychoactive drug use (PDU) is reported in up to 40% of trauma patients and is associated with a higher rate of in-hospital complications. However, little is known about its long-term impact on trauma patients. We aimed to assess the long-term functional, mental, and psychosocial outcomes of PDU in trauma patients 6 to 12 months after injury., Methods: Trauma patients with moderate to severe injuries (Injury Severity Score, >9) who had a toxicology screen upon admission to one of three level 1 trauma centers were contacted by phone 6 to 12 months postinjury. Psychoactive drug use was defined as the presence of a psychoactive, nonprescribed substance on toxicology screen including amphetamine, barbiturate, benzodiazepine, cannabinoid, methamphetamine, methadone, opioid, oxycodone, methylenedioxymethamphetamine (ecstasy), phencyclidine, tricyclic antidepressant, and cocaine. The interviews systematically evaluated functional limitations, social functioning, chronic pain, and mental health (posttraumatic stress disorder, depression, anxiety). Patients with a score of ≤47 on the Short-Form Health Survey version 2.0 social functioning subdomain were considered to have social dysfunction. Multivariable regression models were built to determine the independent association between PDU and long-term outcomes., Results: Of the 1,699 eligible patients, 571 (34%) were included in the analysis, and 173 (30.3%) screened positive for PDU on admission. Patients with PDU were younger (median age [interquartile range], 43 [28-55] years vs. 66 [46-78] years, p < 0.001), had more penetrating injuries (8.7% vs. 4.3%, p = 0.036), and were less likely to have received a college education (41.3% vs. 54.5%, p = 0.004). After adjusting for patients' characteristics including the presence of a baseline psychiatric comorbidity, patients with PDU on admission were more likely to suffer from daily chronic pain, mental health disorders, and social dysfunction 6 to 12 months after injury. There was no difference in the functional limitations between patients with and without PDU., Conclusion: On the long term, PDU in trauma patients is strongly and independently associated with worse mental health, more chronic pain, and severe impairment in social functioning. A trauma hospitalization presents an opportunity to identify patients at risk and to mitigate the long-term impact of PDU on recovery., Level of Evidence: Prognostic/epidemiologic, level III., (Copyright © 2021 American Association for the Surgery of Trauma.)

Background: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis., Methods: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith., Results: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50)., Conclusions: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.)., (Copyright © 2020 Massachusetts Medical Society.)