107 results on '"Deepika Nehra"'
Search Results
2. Community-Level Social Vulnerability and Patterns of Adolescent Injury
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Eustina G. Kwon, MD, MPH, Juan P. Herrera-Escobar, MD, MPH, Eileen M. Bulger, MD, Samuel E. Rice-Townsend, MD, and Deepika Nehra, MD
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Surgery ,RD1-811 - Abstract
Objective:. To describe adolescent injuries by the community-level social vulnerability, focusing on injuries related to interpersonal violence. Background:. The Center for Disease Control and Prevention’s social vulnerability index (SVI) is a tool used to characterize community-level vulnerability. Methods:. Injured adolescent trauma patients (13–17 years old) cared for at a large Level I trauma center over a 10-year period were identified. Injuries were classified by intent as either intentional or unintentional. Census tract level SVI was calculated by composite score and for 4 subindex scores (socioeconomic, household composition/disability, minority/language, housing type/transportation). Patients were stratified by SVI quartile with the lowest quartile designated as low-, the middle two quartiles as average-, and the highest quartile as high vulnerability. The primary outcome was odds of intentional injury. Demographic and injury characteristics were compared by SVI and intent. Multivariable logistic regression was used to estimate the adjusted odds of intentional injury associated with SVI. Results:. A total of 1993 injured adolescent patients (1676 unintentional and 317 intentional) were included. The composite SVI was higher in the intentional injury cohort (mean, SD: 66.7, 27.8 vs. 50.5, 30.2; P < 0.001) as was each subindex SVI. The high SVI cohort comprised 31% of the study population, 49% of intentional injuries, and 51% of deaths. The high SVI cohort had significantly increased unadjusted (odds ratio, 4.5; 95% confidence interval, 3.0–6.6) and adjusted (odds ratio, 1.8; 95% confidence interval, 1.6–2.8) odds of intentional injury. Conclusions:. Adolescents living in the highest SVI areas experience significantly higher odds of intentional injury. SVI and SVI subindex details may provide direction for community-level interventions to decrease the impact of violent injury among adolescents.
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- 2023
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3. Post-traumatic stress disorder (PTSD) symptoms and alcohol and drug use comorbidity at 25 US level I trauma centers
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Eileen M Bulger, Jin Wang, Lauren K Whiteside, Deepika Nehra, Kathleen Moloney, Douglas F Zatzick, Joan Russo, Jefferson Nguyen, and Laura Veach
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Surgery ,RD1-811 ,Medical emergencies. Critical care. Intensive care. First aid ,RC86-88.9 - Abstract
Background Questions regarding the extent to which post-traumatic stress disorder (PTSD) is comorbid with alcohol and drug use are particularly germane in an era when the American College of Surgeons Committee on Trauma (ACS-COT) is considering policy requiring screening, intervention and/or referral services for patients presenting with psychological sequalae of traumatic injury. Literature review revealed few multisite trauma-center-based investigations that have assessed the association between PTSD symptoms and alcohol and drug use comorbidities in injured patients.Methods This investigation was a secondary analysis of baseline data collected prior to randomization in a 25-site trauma center pragmatic clinical trial. All 635 patients included in the investigation had elevated PTSD symptom levels at the time of trauma center admission. Self-report questionnaire screening, laboratory toxicology results, and electronic health record data were combined to assess the frequencies of alcohol, stimulant (i.e., amphetamine and cocaine), opioid and marijuana use comorbidities for injured patients. Logistic regression was used to assess the associations between demographic and injury characteristics and alcohol and drug use comorbidity.Results The frequency of patients with one or more alcohol or substance use comorbidity was between 62% and 79%. Over 50% of patients were positive for one or more alcohol or cannabis comorbidity. Approximately 26% of patients were positive for stimulants and 10% for opioid comorbidity.Discussion This multisite investigation suggests that between 62% and 79% of hospitalized injury survivors with elevated PTSD symptoms have one or more alcohol or drug use comorbidity. Orchestrated ACS-COT policy and trauma center service delivery development should incorporate the key finding that a substantial majority of patients with high levels of psychological distress (eg, elevated PTSD symptoms) may have alcohol and drug use comorbidities.Level of evidence Level II (epidemiological investigation of untreated controls from a multisite randomized clinical trial)Trial registration number NCT02655354.
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- 2022
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4. Leveraging a health information exchange to examine the accuracy of self-report emergency department utilization data among hospitalized injury survivors
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Eileen M Bulger, Lauren K Whiteside, Marie C Vrablik, Deepika Nehra, Kathleen Moloney, Douglas F Zatzick, and Joan Russo
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Surgery ,RD1-811 ,Medical emergencies. Critical care. Intensive care. First aid ,RC86-88.9 - Abstract
Background Accurate acute care medical utilization history is an important outcome for clinicians and investigators concerned with improving trauma center care. The objective of this study was to examine the accuracy of self-report emergency department (ED) utilization compared with utilization obtained from the Emergency Department Information Exchange (EDIE) in admitted trauma surgery patients with comorbid mental health and substance use problems.Methods This is a retrospective cohort study of 169 injured patients admitted to the University of Washington’s Harborview Level I Trauma Center. Patients had high levels of post-traumatic stress disorder and depressive symptoms, suicidal ideation and alcohol comorbidity. The investigation used EDIE, a novel health technology tool that collects information at the time a patient checks into any ED in Washington and other US states. Patterns of EDIE-documented visits were described, and the accuracy of injured patients’ self-report visits was compared with EDIE-recorded visits during the course of the 12 months prior to the index trauma center admission.Results Overall, 45% of the sample (n=76) inaccurately recalled their ED visits during the past year, with 36 participants (21%) reporting less ED visits than EDIE indicated and 40 (24%) reporting more ED visits than EDIE indicated. Patients with histories of alcohol use problems and major psychiatric illness were more likely to either under-report or over-report ED health service use.Discussion Nearly half of all patients were unable to accurately recall ED visits in the previous 12 months compared with EDIE, with almost one-quarter of patients demonstrating high levels of disagreement. The improved accuracy and ease of use when compared with self-report make EDIE an important tool for both clinical and pragmatic trial longitudinal outcome assessments. Orchestrated investigative and policy efforts could further examine the benefits of introducing EDIE and other information exchanges into routine acute care clinical workflows.Level of evidence II/III.Trial registration number ClinicalTrials.gov NCT02274688.
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- 2021
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5. Long-term patient-reported outcome measures after injury: National Trauma Research Action Plan (NTRAP) scoping review protocol
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Adil H Haider, Karen J Brasel, Molly P Jarman, Deborah M. Stein, Jeffrey A Bailey, Deepika Nehra, Zara R Cooper, Juan Pablo Herrera-Escobar, Manuel A Castillo-Angeles, Samia Y Osman, Claudia P Orlas, Mahin B Janjua, Muhammad Abdullah-Arain, Emma Reidy, Pamela J Bixby, Maxwell Braverman, James R Ficke, Nicole S Gibran, Jonathan I. Grone, Bellal A. Joseph, Craig D. Newgard, and Edward S. Shipper
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Surgery ,RD1-811 ,Medical emergencies. Critical care. Intensive care. First aid ,RC86-88.9 - Abstract
Background A significant proportion of patients who survive traumatic injury continue to suffer impaired functional status and increased mortality long after discharge. However, despite the need to improve long-term outcomes, trauma registries in the USA do not collect data on outcomes or care processes after discharge. One of the main barriers is the lack of consensus regarding the optimal outcome metrics.Objectives To describe the methodology of a scoping review evaluating current evidence on the available measures for tracking functional and patient-reported outcomes after injury. The aim of the review was to identify and summarize measures that are being used to track long-term functional recovery and patient-reported outcomes among adults after injury.Methods A systematic search of PubMed and Embase will be performed using the search terms for the population (adult trauma patients), type of outcomes (long-term physical, mental, cognitive, and quality of life), and measures available to track them. Studies identified will be reviewed and assessed for relevance by at least two reviewers. Data will be extracted and summarized using descriptive statistics and a narrative synthesis of the results. This protocol is being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.Dissemination This scoping review will provide information regarding the currently available metrics for tracking functional and patient-reported outcomes after injury. The review will be presented to a multi-disciplinary stakeholder group that will evaluate these outcome metrics using an online Delphi approach to achieve consensus as part of the development of the National Trauma Research Action Plan (NTRAP). The results of this review will be presented at relevant national surgical conferences and published in peer-reviewed scientific journals.
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- 2020
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6. Rapid ethnographic assessment of the COVID-19 pandemic April 2020 ‘surge’ and its impact on service delivery in an Acute Care Medical Emergency Department and Trauma Center
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Mark Taylor, Allison Engstrom, Lawrence A Palinkas, Lauren Whiteside, Deepika Nehra, Kathleen Moloney, and Douglas F Zatzick
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Medicine - Abstract
Objectives Assess the impacts of the COVID-19 pandemic on service delivery by frontline healthcare providers in acute care medical and emergency department settings and identify strategies used to cope with pandemic-related physical and mental health demands.Design Rapid clinical ethnography of patient–provider encounters during an initial pandemic ‘surge’ conducted by a team of clinician–researchers using a structured protocol for qualitative data collection and analysis.Setting Level 1 trauma centre at Harborview Hospital in Seattle Washington in April 2020.Participants Frontline clinical providers serving as participant observers during performance of their clinical duties recorded observations and summaries of conversations with other providers and patients.Results We identified four different kinds of impacts: procedural, provider, patient and overall. Each impact highlighted two or more levels of a socioecological model of services delivery: (1) the epidemiology of COVID-19, (2) outer setting, (3) inner or organisational setting and (4) individual patient and provider. Despite significant changes in procedures that included COVID-19 screening of all admitted patients, social distancing and use of personal protective equipment, as well as changes in patient and provider behaviour, the overall impact of the pandemic on the emergency department and acute care service delivery was minimal. This is attributed to having a smaller surge than expected, a quick response by the healthcare system to anticipated demands for service delivery and protection of patients and providers, adequate supplies and high provider morale.Conclusions Although limited to one setting in one healthcare system in one community, the findings offer some important lessons for healthcare systems that have yet to be impacted as well as systems that have been more severely impacted. Each of the socioecological framework levels was found to impact service delivery to patients, and variations at each of these levels account for variations in that quality of care globally.
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- 2020
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7. Proceedings from the Second Medical Summit on Firearm Injury Prevention, 2022: Creating a Sustainable Healthcare Coalition to Advance a Multidisciplinary Public Health Approach
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Joseph V Sakran, Sue S Bornstein, Rochelle Dicker, Frederick P Rivara, Brendan T Campbell, Rebecca M Cunningham, Marian Betz, Stephen Hargarten, Ashley Williams, Joshua M Horwitz, Deepika Nehra, Helen Burstin, Karen Sheehan, Fatimah L Dreier, Thea James, Chethan Sathya, John H Armstrong, Ali Rowhani-Rahbar, Scott Charles, Amy Goldberg, Lois K Lee, Ronald M Stewart, Jeffrey D Kerby, Patricia L Turner, and Eileen M Bulger
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Surgery - Published
- 2023
8. The association between childhood opportunity index and pediatric hospitalization for firearm injury or motor vehicle crash
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Eustina G. Kwon, Deepika Nehra, Matthew Hall, Juan P. Herrera-Escobar, Frederick P. Rivara, and Samuel E. Rice-Townsend
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Surgery - Published
- 2023
9. Patterns in Location of Death From Firearm Injury in the US
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Lauren L. Agoubi, Ning Duan, Ali Rowhani-Rahbar, Deepika Nehra, Joseph V. Sakran, and Frederick P. Rivara
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Surgery - Abstract
This cross-sectional study assesses non–self-inflicted firearm-related deaths occurring at inpatient or outpatient facilities, hospice care, nursing homes, home, or other settings from 1999 to 2021.
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- 2023
10. The Social Vulnerability Index and Long-term Outcomes After Traumatic Injury
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Juan P, Herrera-Escobar, Tarsicio, Uribe-Leitz, Joyce, Wang, Claudia P, Orlas, Mohamad El, Moheb, Taylor E, Lamarre, Niha, Ahmad, Ka Man, Hau, Molly, Jarman, Nomi C, Levy-Carrick, Sabrina E, Sanchez, Haytham M A, Kaafarani, Ali, Salim, and Deepika, Nehra
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Adult ,Male ,Stress Disorders, Post-Traumatic ,Social Vulnerability ,Trauma Centers ,Humans ,Female ,Surgery ,Middle Aged ,Needs Assessment - Abstract
The aim of this study was to evaluate the Social Vulnerability Index (SVI) as a predictor of long-term outcomes after injury.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.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.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.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.
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- 2022
11. Nationwide Survey of Trauma Center Screening and Intervention Practices for Posttraumatic Stress Disorder, Firearm Violence, Mental Health, and Substance Use Disorders
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Eileen M, Bulger, Peyton, Johnson, Lea, Parker, Kathleen E, Moloney, Michelle K, Roberts, Natalie, Vaziri, Sara, Seo, Deepika, Nehra, Peter, Thomas, and Douglas, Zatzick
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Stress Disorders, Post-Traumatic ,Firearms ,Mental Health ,Trauma Centers ,Substance-Related Disorders ,Humans ,Wounds, Gunshot ,Surgery ,Violence - Abstract
Posttraumatic stress disorder (PTSD) symptoms, firearm violence events, alcohol and drug use problems, and major depression and suicidal ideation are endemic among patients admitted to US trauma centers. Despite increasing policy importance, the current availability of screening and intervention services for this constellation of conditions in US trauma centers is unknown.Trauma program staff at all Level I and Level II trauma centers in the US. (N = 627) were contacted to complete a survey describing screening and intervention procedures for alcohol and drug use problems, PTSD symptoms, depression and suicidality, and firearm violence. Additional questions asked trauma centers about the delivery of peer interventions and information technology capacity for screening and intervention procedures.Fifty-one percent of trauma centers (n = 322) responded to the survey. More than 95% of responding sites endorsed routinely screening and/or intervening for alcohol use problems. Routine services addressing PTSD were less common, with 28% of centers reporting routine screening. More than 50% of sites that screened for PTSD used previously established trauma center alcohol use services. Programmatic screening and intervention for firearm injury sequelae was occurring at 30% of sites.Alcohol screening and intervention is occurring frequently at US trauma centers and appears to be responsive to American College of Surgeons Committee on Trauma verification requirements. Routine screening and intervention services for PTSD and firearm injury were occurring less frequently. Regular national surveys may be a key element of tracking progress in national mental health and substance use screening, intervention, and referral policy.
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- 2022
12. Impact of chronic illness on functional outcomes and quality of life among injured older adults
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Ewelina Stanek, Timothy Klepp, Ali Salim, Zara Cooper, Deepika Nehra, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, and Claire Sokas
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medicine.medical_specialty ,Psychological intervention ,Aftercare ,Trauma registry ,Odds ,03 medical and health sciences ,0302 clinical medicine ,Trauma Centers ,Quality of life ,medicine ,Humans ,Aged ,General Environmental Science ,030222 orthopedics ,business.industry ,030208 emergency & critical care medicine ,Emergency department ,Trauma care ,Mental health ,Patient Discharge ,Chronic Disease ,Emergency medicine ,Quality of Life ,Wounds and Injuries ,General Earth and Planetary Sciences ,Injury Severity Score ,business - Abstract
Trauma care for injured older adults is complicated by pre-existing chronic illness. We examined the association between chronic illness and post-injury function, healthcare utilization and quality of life.Trauma patients ≥65 years with an Injury Severity Score (ISS) ≥9 discharged from one of three level-1 trauma centers were interviewed 6-12 months post-discharge. Patients were asked about new functional limitations, injury-related emergency department (ED) visits or readmission, and health-related quality of life (HRQoL). Trauma registry data was used to determine presence of seven chronic illnesses. Adjusted regression models examined associations between increasing number of chronic illness (0, 1, ≥2) and outcomes.Of 1,379 patients, 46.5% had at least one chronic illness. In adjusted analysis, any chronic illness was associated with higher odds of new functional limitation (1 chronic illness, OR1.54, CI: 1.20-1.97; ≥2, OR1.69, CI: 1.16-2.48) and worse physical health-related QoL (1 chronic illness adj. mean diff= -4.0, CI: -5.6 to -2.5; ≥2 adj. mean diff.= -4.4, CI: -7.3 to -1.4, p0.01). Mental health post-injury was consistent with population norms across all groups.Presence of any chronic illness in older adults is associated with new functional limitations and worse physical HRQoL post-injury, but unchanged mental health. Focused interventions are needed to support long-term recovery.
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- 2021
13. Impact of the COVID-19 Pandemic on Long-term Recovery From Traumatic Injury
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George C. Velmahos, Joyce Wang, Claudia P. Orlas, Ali Salim, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Nikita Patel, Nomi C Levy-Carrick, Deepika Nehra, Sabrina E. Sanchez, Taylor Lamarre, and Mohamad El Moheb
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Social stress ,education.field_of_study ,medicine.medical_specialty ,business.industry ,Population ,Mental health ,Traumatic injury ,Health care ,Pandemic ,Cohort ,Emergency medicine ,Medicine ,Surgery ,business ,education ,Depression (differential diagnoses) - Abstract
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 6-14 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 (SES), 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 SF-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.
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- 2021
14. Long-Term Functional Outcomes of Trauma Patients With Facial Injuries
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Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Mohamad El Moheb, Ali Salim, Shekhar K. Gadkaree, Deepika Nehra, George C. Velmahos, Edward J Caterson, and Justin C. McCarty
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Facial trauma ,medicine.medical_specialty ,business.industry ,Head injury ,MEDLINE ,General Medicine ,After discharge ,medicine.disease ,Polytrauma ,Otorhinolaryngology ,Quality of life ,Healthcare utilization ,Emergency medicine ,Medicine ,Surgery ,business ,Cohort study - Abstract
Background Facial trauma can have long-lasting consequences on an individual's physical, mental, and social well-being. The authors sought to assess the long-term outcomes of patients with facial injuries. Methods This is a prospective multicenter cohort study of patients with face abbreviated injury scores ≥1 within the Functional Outcomes and Recovery after Trauma Emergencies registry. The Functional Outcomes and Recovery after Trauma Emergencies registry collects patient-reported outcomes data for patients with moderate-severe trauma 6 to 12 months after injury. Outcomes variables included general and trauma-specific quality of life, functional limitations, screening for post-traumatic stress disorder, and postdischarge healthcare utilization. Results A total of 188 patients with facial trauma were included: 69.1% had an isolated face and/or head injury and 30.9% had a face and/or head injuries as a part of polytrauma injury. After discharge, 11.7% of patients visited the emergency room, and 13.3% were re-admitted to the hospital. Additionally, 36% of patients suffered from functional limitations and 17% of patients developed post-traumatic stress disorder. A total of 34.3% patients reported that their injury scars bothered them, and 49.4% reported that their injuries were hard to deal with emotionally. Conclusions Patients who sustain facial trauma suffer significant long-term health-related quality of life consequences stemming from their injuries.
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- 2021
15. Interpersonal violence affecting the pediatric population: Patterns of injury and recidivism
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Eustina G. Kwon, Benjamin K. Wang, Katherine R. Iverson, Kathleen M. O'Connell, Deepika Nehra, and Samuel E. Rice-Townsend
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Pediatrics, Perinatology and Child Health ,Surgery ,General Medicine - Abstract
We aim to describe interpersonal violence-related injury patterns in the pediatric trauma population and to identify predictors of recidivism.In this retrospective analysis from a single institution, we included pediatric patients (≤17 years) treated (2006-2020) for traumatic injury related to interpersonal violence (IPV). Patient characteristics were compared among mechanism types and between recidivists and non recidivists using two sample t-tests, Wilcoxon rank-sum tests, and Pearson's chi-squared. Multivariate analysis was performed using logistic regression to identify predictors of repeat injury.We identified 635 pediatric patients who sustained injuries owning to IPV: firearm (N = 266), assault (stab/blunt; N = 243), and abuse (N = 126). The average age of the firearm, assault, and abuse groups was 15.5, 14.7, and 1.1 years (SD = 2.2, 3.4, 2.4 years), respectively. Majority of the overall cohort was male (77.5%) and publicly- or un insured (67.8%), with 28.0% being Black. Of the 489 firearm and assault patients who survived the first injury, 30 (6.1%) had repeat injury owning to IPV requiring treatment at our center with a median time of 40 months (IQR 17-62 months) between first and second injury. The majority of recidivists (83.3%) were victims of gun violence whereas the distribution between assault and firearm in the non recidivists was more even at 51 and 49%, respectively (p 0.001). Eighteen (60.0%) of the recidivist patients had the same mechanism between the first and second injury. In the logistic regression analysis, Black race and firearm injury were associated with greater than 3-fold higher likelihood of repeat injury compared to white race after adjusting for age, sex, insurance, and child opportunity index.We found that survivors of firearm injuries and assault comprise a vulnerable patient cohort at risk for repeat injury, and Black race is an independent predictor of repeat injury owning to IPV. These findings provide guidance for developing violence prevention programs.Retrospective Comparative Study LEVEL OF EVIDENCE: Level III.
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- 2022
16. Patient reported outcomes 6 to 12 months after interpersonal violence: A multicenter cohort study
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Adil H. Haider, Manuel Castillo-Angeles, Deepika Nehra, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Alexander Toppo, Sabrina E. Sanchez, and Ali Salim
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Adult ,Male ,medicine.medical_specialty ,Activities of daily living ,Violence ,Critical Care and Intensive Care Medicine ,Cohort Studies ,Stress Disorders, Post-Traumatic ,Young Adult ,Injury Severity Score ,Return to Work ,Trauma Centers ,Quality of life ,Surveys and Questionnaires ,Activities of Daily Living ,Epidemiology ,medicine ,Humans ,Patient Reported Outcome Measures ,Crime Victims ,business.industry ,Chronic pain ,Odds ratio ,Middle Aged ,medicine.disease ,United States ,Logistic Models ,Mental Health ,Emergency medicine ,Quality of Life ,Wounds and Injuries ,Female ,Surgery ,Chronic Pain ,business ,Psychosocial ,Cohort study - Abstract
PURPOSE Violence continues to be a significant public health burden, but little is known about the long-term outcomes of these patients. Our goal was to determine the impact of violence-related trauma on long-term functional and psychosocial outcomes. METHODS We identified trauma patients with moderate to severe injuries (Injury Severity Score, ≥9) treated at one of three level 1 trauma centers. These patients were asked to complete a survey over the phone between 6 and 12 months after injury evaluating both functional and psychosocial outcomes (12-item Short Form Survey, Trauma Quality of Life, posttraumatic stress disorder [PTSD] screen, chronic pain, return to work). Patients were classified as having suffered a violent injury if the mechanism of injury was a stab, gunshot, or assault. Self-inflicted wounds were excluded. Adjusted logistic regression models were built to determine the association between a violent mechanism of injury and long-term outcomes. RESULTS A total of 1,050 moderate to severely injured patients were successfully followed, of whom 176 (16.8%) were victims of violence. For the victims of violence, mean age was 34.4 years (SD, 12.5 years), 85% were male, and 57.5% were Black; 30.7% reported newly needing help with at least one activity of daily living after the violence-related event. Fifty-nine (49.2%) of 120 patients who were working before their injury had not yet returned to work; 47.1% screened positive for PTSD, and 52.3% reported chronic pain. On multivariate analysis, a violent mechanism was significantly associated with PTSD (odds ratio, 2.57; 95% confidence interval, 1.59-4.17; p < 0.001) but not associated with chronic pain, return to work, or functional outcomes. CONCLUSION The physical and mental health burden after violence-related trauma is not insignificant. Further work is needed to identify intervention strategies and social support systems that may be beneficial to reduce this burden. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
- Published
- 2021
17. Association of Community Vulnerability and State Gun Laws With Firearm Deaths in Children and Adolescents Aged 10 to 19 Years
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Eustina G. Kwon, Samuel E. Rice-Townsend, Lauren L. Agoubi, Ali Rowhani-Rahbar, and Deepika Nehra
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General Medicine - Abstract
ImportanceFirearm-related injuries are the leading cause of death among children and adolescents in the US. For youths aged 10 to 19 years, 64% of firearm-related deaths are due to assault. Understanding the association between the rate of death due to assault-related firearm injury and both community-level vulnerability and state-level gun laws may inform prevention efforts and public health policy.ObjectiveTo assess the rate of death due to assault-related firearm injury stratified by community-level social vulnerability and state-level gun laws in a national cohort of youths aged 10 to 19 years.Design, Setting, and ParticipantsThis national cross-sectional study used the Gun Violence Archive to identify all assault-related firearm deaths among youths aged 10 to 19 years occurring in the US between January 1, 2020, and June 30, 2022.ExposureCensus tract–level social vulnerability (measured by the Centers for Disease Control and Prevention social vulnerability index [SVI]; categorized in quartiles as low [75th percentile]) and state-level gun laws (measured by the Giffords Law Center gun law scorecard rating; categorized as restrictive, moderate, or permissive).Main Outcomes and MeasuresYouth death rate (per 100 000 person-years) due to assault-related firearm injury.ResultsAmong 5813 youths aged 10 to 19 years who died of an assault-related firearm injury over the 2.5-year study period, the mean (SD) age was 17.1 (1.9) years, and 4979 (85.7%) were male. The death rate per 100 000 person-years in the low SVI cohort was 1.2 compared with 2.5 in the moderate SVI cohort, 5.2 in the high SVI cohort, and 13.3 in the very high SVI cohort. The mortality rate ratio of the very high SVI cohort compared with the low SVI cohort was 11.43 (95% CI, 10.17-12.88). When further stratifying deaths by the Giffords Law Center state-level gun law scorecard rating, the stepwise increase in death rate (per 100 000 person-years) with increasing SVI persisted, regardless of whether the Census tract was in a state with restrictive gun laws (0.83 in the low SVI cohort vs 10.11 in the very high SVI cohort), moderate gun laws (0.81 in the low SVI cohort vs 13.18 in the very high SVI cohort), or permissive gun laws (1.68 in the low SVI cohort vs 16.03 in the very high SVI cohort). The death rate per 100 000 person-years was higher for each SVI category in states with permissive compared with restrictive gun laws (eg, moderate SVI: 3.37 vs 1.71; high SVI: 6.33 vs 3.78).Conclusions and RelevanceIn this study, socially vulnerable communities in the US experienced a disproportionate number of assault-related firearm deaths among youths. Although stricter gun laws were associated with lower death rates in all communities, these gun laws did not equalize the consequences on a relative scale, and disadvantaged communities remained disproportionately impacted. While legislation is necessary, it may not be sufficient to solve the problem of assault-related firearm deaths among children and adolescents.
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- 2023
18. Exploring Racialized Economic Segregation and Reinjury and Violence Perpetration Among Survivors of Violent Injuries
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Meera Kotagal, Deepika Nehra, and Rochelle Dicker
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General Medicine - Published
- 2023
19. Recidivism after Interpersonal Violence: Who Is at Greatest Risk?
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Eustina G Kwon, Benjamin Wang, Katherine T Iverson, Saman Arbabi, Eileen Metzger Bulger, Samuel E Rice-Townsend, and Deepika Nehra
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Surgery - Published
- 2023
20. Long-term patient-reported outcomes and patient-reported outcome measures after injury: the National Trauma Research Action Plan (NTRAP) scoping review
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Molly P. Jarman, Emma Reidy, Angel Rosario, Juan P. Herrera-Escobar, Michelle A. Price, Muhammad Abdullah Arain, Eileen M. Bulger, Sophiya Das, Alexander Toppo, Samia Y Osman, Deepika Nehra, Manuel Castillo-Angeles, Claudia P. Orlas, Mahin Janjua, and Adil H. Haider
- Subjects
medicine.medical_specialty ,injury ,MEDLINE ,Critical Care and Intensive Care Medicine ,outcome measures ,03 medical and health sciences ,0302 clinical medicine ,Quality of life (healthcare) ,Outcome Assessment, Health Care ,Humans ,Medicine ,Patient Reported Outcome Measures ,Social determinants of health ,Randomized Controlled Trials as Topic ,Patient-reported outcomes ,business.industry ,030208 emergency & critical care medicine ,Evidence-based medicine ,Mental health ,Systematic review ,ComputingMethodologies_DOCUMENTANDTEXTPROCESSING ,Quality of Life ,Physical therapy ,Wounds and Injuries ,Surgery ,Patient-reported outcome ,Observational study ,Systematic Review ,business ,long-term outcomes - Abstract
Supplemental digital content is available in the text., BACKGROUND The aim of this scoping review is to identify and summarize patient-reported outcome measures (PROMs) that are being used to track long-term patient-reported outcomes (PROs) after injury and can potentially be included in trauma registries. METHODS Online databases were used to identify studies published between 2013 and 2019, from which we selected 747 articles that involved survivors of acute physical traumatic injury aged 18 years or older at time of injury and used PROMs to evaluate recovery between 6 months and 10 years postinjury. Data were extracted and summarized using descriptive statistics and a narrative synthesis of the results. RESULTS Most studies were observational, with relatively small sample sizes, and predominantly on traumatic brain injury or orthopedic patients. The number of PROs assessed per study varied from one to 12, for a total of 2052 PROs extracted, yielding 74 unique constructs (physical health, 25 [34%]; mental health, 27 [37%]; social health, 12 [16%]; cognitive health, 7 [10%]; and quality of life, 3 [4%]). These 74 constructs were assessed using 355 different PROMs. Mental health was the most frequently examined outcome domain followed by physical health. Health-related quality of life, which appeared in more than half of the studies (n = 401), was the most common PRO evaluated, followed by depressive symptoms. Physical health was the domain with the highest number of PROMs used (n = 157), and lower-extremity functionality was the PRO that contributed most PROMs (n = 33). CONCLUSION We identified a wide variety of PROMs available to track long-term PROs after injury in five different health domains: physical, mental, social, cognitive, and quality of life. However, efforts to fully understand the health outcomes of trauma patients remain inconsistent and insufficient. Defining PROs that should be prioritized and standardizing the PROMs to measure them will facilitate the incorporation of long-term outcomes in national registries to improve research and quality of care. LEVEL OF EVIDENCE Systematic Reviews & Meta-analyses, Level IV
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- 2021
21. Management of Crown Rot of Cucumber (Fusarium solani) through Integrated Practices and Organic Amendments
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Deepika Nehra, Lalita Lakhran, and R.R. Ahir
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Horticulture ,biology ,Crown (botany) ,biology.organism_classification ,Fusarium solani - Published
- 2020
22. Mental Health Burden After Injury
- Author
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Ali Salim, Nomi C Levy-Carrick, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Ewelina Stanek, Kaye Lu, Sabrina E. Sanchez, Anupamaa J Seshadri, Kelsey Han, and Deepika Nehra
- Subjects
Male ,medicine.medical_specialty ,Poison control ,Stress Disorders, Post-Traumatic ,Injury Severity Score ,Return to Work ,Trauma Centers ,Internal medicine ,mental disorders ,Injury prevention ,Prevalence ,Humans ,Medicine ,Depression (differential diagnoses) ,Psychiatric Status Rating Scales ,Depressive Disorder ,business.industry ,Chronic pain ,Recovery of Function ,Odds ratio ,Middle Aged ,medicine.disease ,Anxiety Disorders ,Mental health ,Patient Outcome Assessment ,Quality of Life ,Wounds and Injuries ,Anxiety ,Female ,Surgery ,Chronic Pain ,medicine.symptom ,business ,Boston - Abstract
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.
- Published
- 2020
23. Child physical abuse and COVID-19: Trends from nine pediatric trauma centers
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Aaron R. Jensen, Joseph D. Tobias, Deepika Nehra, Jill L. Kaar, John M. Perry, Lauren L. Evans, Zachary J. Kastenberg, Autumn V. Rohan, Melissa L. Anderson, Eric R. Scaife, Niti Shahi, Romeo C. Ignacio, Jacky Z. Kwong, Antoinette L. Laskey, Stephanie D. Chao, Kaci Pickett, Erin M. Garvey, Katrine Lofberg, Katie W. Russell, David Bliss, Shannon N. Acker, Caitlin A. Smith, and Brittney L. Bunnell
- Subjects
Child abuse ,Adult ,medicine.medical_specialty ,Physical Injury - Accidents and Adverse Effects ,Coronavirus disease 2019 (COVID-19) ,Child Abuse and Neglect Research ,Pediatrics ,Unintentional Childhood Injury ,Paediatrics and Reproductive Medicine ,Trauma Centers ,Clinical Research ,Pandemic ,Pediatric surgery ,Nonaccidental trauma ,medicine ,Humans ,Child Abuse ,Child ,Pandemics ,Retrospective Studies ,Violence Research ,Pediatric ,business.industry ,SARS-CoV-2 ,Prevention ,Stressor ,COVID-19 ,General Medicine ,Injuries and accidents ,Wptc Papers ,medicine.disease ,Childhood Injury ,Child physical abuse ,Physical abuse ,Good Health and Well Being ,Physical Abuse ,Pediatrics, Perinatology and Child Health ,Emergency medicine ,HIV/AIDS ,Surgery ,Patient Safety ,business ,Pediatric trauma - Abstract
Background Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with “shelter-in-place orders”, may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period. Methods We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data. Results There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality. Conclusions Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.
- Published
- 2022
24. Patient-reported outcomes 6 to 12 months after isolated rib fractures: A nontrivial injury pattern
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Haytham M.A. Kaafarani, Jessica Serventi-Gleeson, Mohamad El Moheb, Annie Heyman, Patrick Heindel, Deepika Nehra, Alexander Ordoobadi, Shannon Garvey, Juan Herrera Escobar, Ali Salim, Nikita Patel, and Sabrina E. Sanchez
- Subjects
Male ,medicine.medical_specialty ,Activities of daily living ,Rib Fractures ,Critical Care and Intensive Care Medicine ,Logistic regression ,Blunt ,Quality of life ,Internal medicine ,medicine ,Humans ,Patient Reported Outcome Measures ,Prospective Studies ,Registries ,Aged ,Pain Measurement ,Retrospective Studies ,Pain disorder ,Exercise Tolerance ,business.industry ,Chronic pain ,Evidence-based medicine ,Recovery of Function ,Middle Aged ,medicine.disease ,Cohort ,Abbreviated Injury Scale ,Quality of Life ,Surgery ,Female ,Chronic Pain ,business - Abstract
Despite the ubiquity of rib fractures in patients with blunt chest trauma, long-term outcomes for patients with this injury pattern are not well described.The Functional Outcomes and Recovery after Trauma Emergencies (FORTE) project has established a multicenter prospective registry with 6- to 12-month follow-up for trauma patients treated at participating centers. We combined the FORTE registry with a detailed retrospective chart review investigating admission variables and injury characteristics. All trauma survivors with complete FORTE data and isolated chest trauma (Abbreviated Injury Scale score of ≤1 in all other regions) with rib fractures were included. Outcomes included chronic pain, limitation in activities of daily living, physical limitations, exercise limitations, return to work, and both inpatient and discharge pain control modalities. Multivariable logistic regression models were built for each outcome using clinically relevant demographic and injury characteristic univariate predictors.We identified 279 patients with isolated rib fractures. The median age of the cohort was 68 years (interquartile range, 56-78 years), 59% were male, and 84% were White. Functional and quality of life limitations were common among survivors of isolated rib fractures even 6 to 12 months after injury. Forty-three percent of patients without a preexisting pain disorder reported new daily pain, and new chronic pain was associated with low resilience. Limitations in physical functioning and exercise capacity were reported in 56% and 51% of patients, respectively. Of those working preinjury, 28% had not returned to work. New limitations in activities of daily living were reported in 29% of patients older than 65 years. Older age, higher number of rib fractures, and intensive care unit admission were independently associated with higher odds of receiving regional anesthesia. Receiving a regional nerve block did not have a statistically significant association with any patient-reported outcome measures.Isolated rib fractures are a nontrivial trauma burden associated with functional impairment and chronic pain even 6 to 12 months after injury.Prognostic/epidemiologic, level III.
- Published
- 2021
25. Patient-Reported Outcomes at 6-12 Months for Injured Octogenarian, Nonagenarian, and Centenarian Patients
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Anthony Gebran, Jefferson Alejandro Proaño Zamudio, Juan P Herrera-Escobar, Angela Renne, Taylor Lamarre, Sabrina E Sanchez, Ali Salim, George C Velmahos, Haytham MA Kaafarani, and Deepika Nehra
- Subjects
Surgery - Published
- 2022
26. Impact of the COVID-19 Pandemic on Long-term Recovery From Traumatic Injury
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Juan P, Herrera-Escobar, Joyce, Wang, Taylor, Lamarre, Nikita, Patel, Claudia P, Orlas, Mohamad, El Moheb, Nomi C, Levy-Carrick, Sabrina E, Sanchez, George, Velmahos, Haytham Ma, Kaafarani, Ali, Salim, and Deepika, Nehra
- Subjects
Male ,Time Factors ,SARS-CoV-2 ,COVID-19 ,Comorbidity ,Recovery of Function ,Middle Aged ,Stress Disorders, Post-Traumatic ,Surveys and Questionnaires ,Quality of Life ,Humans ,Female ,Prospective Studies ,Survivors ,Pandemics ,Follow-Up Studies - Abstract
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.The COVID-19 pandemic has precipitated physical, psychological, and social stressors that may create a uniquely difficult recovery and reintegration environment for injured patients.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.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.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.
- Published
- 2021
27. Long-Term Functional Outcomes of Trauma Patients With Facial Injuries
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Justin C, McCarty, Juan P, Herrera-Escobar, Shekhar K, Gadkaree, Mohamad, El Moheb, Haytham M A, Kaafarani, George, Velmahos, Ali, Salim, Deepika, Nehra, and Edward J, Caterson
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Cohort Studies ,Quality of Life ,Aftercare ,Humans ,Wounds and Injuries ,Prospective Studies ,Facial Injuries ,Patient Discharge - Abstract
Facial trauma can have long-lasting consequences on an individual's physical, mental, and social well-being. The authors sought to assess the long-term outcomes of patients with facial injuries.This is a prospective multicenter cohort study of patients with face abbreviated injury scores ≥1 within the Functional Outcomes and Recovery after Trauma Emergencies registry. The Functional Outcomes and Recovery after Trauma Emergencies registry collects patient-reported outcomes data for patients with moderate-severe trauma 6 to 12 months after injury. Outcomes variables included general and trauma-specific quality of life, functional limitations, screening for post-traumatic stress disorder, and postdischarge healthcare utilization.A total of 188 patients with facial trauma were included: 69.1% had an isolated face and/or head injury and 30.9% had a face and/or head injuries as a part of polytrauma injury. After discharge, 11.7% of patients visited the emergency room, and 13.3% were re-admitted to the hospital. Additionally, 36% of patients suffered from functional limitations and 17% of patients developed post-traumatic stress disorder. A total of 34.3% patients reported that their injury scars bothered them, and 49.4% reported that their injuries were hard to deal with emotionally.Patients who sustain facial trauma suffer significant long-term health-related quality of life consequences stemming from their injuries.
- Published
- 2021
28. Catalyzing the Translation of Patient-Centered Research Into United States Trauma Care Systems: A Case Example
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Lawrence A. Palinkas, Kathleen Moloney, Lauren K. Whiteside, Peter Thomas, Deepika Nehra, Eileen M. Bulger, Douglas F. Zatzick, and Kristina Anderson
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medicine.medical_specialty ,Comparative Effectiveness Research ,Emergency Medical Services ,Translational Research, Biomedical ,Stakeholder Participation ,Political science ,Patient-Centered Care ,Health care ,medicine ,Humans ,Transitional care ,Medical education ,Clinical ethnography ,Patient-Centered Outcomes Research Institute Transitional Care Evidence to Action Network ,business.industry ,Health Policy ,Public Health, Environmental and Occupational Health ,Stakeholder ,Health Plan Implementation ,Transitional Care ,Original Articles ,trauma care systems policy ,United States ,Patient Outcome Assessment ,comparative effectiveness trials ,Intervention (law) ,Conceptual framework ,Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) ,Outcomes research ,pragmatic clinical trials ,Construct (philosophy) ,business ,Delivery of Health Care - Abstract
Background The expedient translation of research findings into sustainable intervention procedures is a longstanding health care system priority. The Patient-Centered Outcomes Research Institute (PCORI) has facilitated the development of "research done differently," with a central tenet that key stakeholders can be productively engaged throughout the research process. Literature review revealed few examples of whether, as originally posited, PCORI's innovative stakeholder-driven approach could catalyze the expedient translation of research results into practice. Objectives This narrative review traces the historical development of an American College of Surgeons Committee on Trauma (ACS/COT) policy guidance, facilitated by evidence supplied by the PCORI-funded studies evaluating the delivery of patient-centered care transitions. Key elements catalyzing the guidance are reviewed, including the sustained engagement of ACS/COT policy stakeholders who have the capacity to invoke system-level implementation strategies, such as regulatory mandates linked to verification site visits. Other key elements, including the encouragement of patient stakeholder voice in policy decisions and the incorporation of end-of-study policy summits in pragmatic comparative effectiveness trial design, are discussed. Conclusions Informed by comparative effectiveness trials, ACS/COT policy has expedited introduction of the patient-centered care construct into US trauma care systems. A comparative health care systems conceptual framework for transitional care which incorporates Research Lifecycle, pragmatic clinical trial and implementation science models is articulated. When combined with Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE), employed as a targeted implementation strategy, this approach may accelerate the sustainable delivery of high-quality patient-centered care transitions for US trauma care systems.
- Published
- 2021
29. A Prospective US National Trauma Center Study of Firearm Injury Survivors Weapon Carriage and Posttraumatic Stress Disorder Symptoms
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Kristina Anderson, Joan Russo, Deepika Nehra, Douglas F. Zatzick, Kathleen Moloney, Ronald V. Maier, Eileen M. Bulger, and Jin Wang
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Adult ,Male ,medicine.medical_specialty ,Firearms ,Violence ,Article ,law.invention ,Stress Disorders, Post-Traumatic ,Young Adult ,Randomized controlled trial ,Trauma Centers ,law ,Risk Factors ,Injury prevention ,Medicine ,Humans ,Prospective Studies ,Survivors ,Young adult ,Prospective cohort study ,Social Behavior ,business.industry ,Trauma center ,Middle Aged ,Confidence interval ,United States ,Carriage ,Relative risk ,Emergency medicine ,Surgery ,Female ,Wounds, Gunshot ,business - Abstract
OBJECTIVE To describe the demographic, injury-related, and mental health characteristics of firearm injury patients and trace firearm weapon carriage and PTSD symptoms over the year after injury. SUMMARY AND BACKGROUND DATA Based on the increasing incidence of firearm injury and need for novel injury prevention strategies, hospital-based violence intervention programs are being implemented in US trauma centers. There is limited data on the long-term outcomes and risk behaviors of firearm injury survivors to guide this work. METHODS We conducted a secondary analysis of a pragmatic 25-trauma center randomized trial (N = 635). Baseline characteristics of firearm-injured patients (N = 128) were compared with other trauma patients. Mixed model regression was used to identify risk factors for postinjury firearm weapon carriage and PTSD symptoms. RESULTS Firearm injury patients were younger and more likely to be black, male and of lower socioeconomic status, and more likely to carry a firearm in the year before injury. Relative to preinjury, there was a significant drop in firearm weapon carriage at 3- and 6-months postinjury, followed by a return to preinjury levels at 12-months. Firearm injury was significantly and independently associated with an increased risk of postinjury firearm weapon carriage [relative risk = 2.08, 95% confidence interval (1.34, 3.22), P < 0.01] and higher PTSD symptom levels [Beta = 3.82, 95% confidence interval (1.29, 6.35), P < 0.01]. CONCLUSIONS Firearm injury survivors are at risk for firearm carriage and high PTSD symptom levels postinjury. The significant decrease in the high-risk behavior of firearm weapon carriage at 3-6 months postinjury suggests that there is an important postinjury "teachable moment" that should be targeted with preventive interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT02655354.
- Published
- 2021
30. Perceived social support is strongly associated with recovery after injury
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Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Sabrina E. Sanchez, Deepika Nehra, Andriana Velmahos, Ka Man Hau, Claudia P. Orlas, Ali Salim, and Nikita Patel
- Subjects
Adult ,Male ,medicine.medical_specialty ,Anxiety ,Critical Care and Intensive Care Medicine ,Logistic regression ,Risk Assessment ,Stress Disorders, Post-Traumatic ,Social support ,Injury Severity Score ,Trauma Centers ,Risk Factors ,medicine ,Humans ,Depression (differential diagnoses) ,Aged ,Aged, 80 and over ,Psychiatric Status Rating Scales ,business.industry ,Depression ,Confounding ,Chronic pain ,Social Support ,Evidence-based medicine ,Recovery of Function ,Middle Aged ,medicine.disease ,Mental health ,Patient Discharge ,Logistic Models ,Massachusetts ,Physical therapy ,Linear Models ,Quality of Life ,Wounds and Injuries ,Surgery ,Female ,medicine.symptom ,business - Abstract
BACKGROUND The strength of one's social support network is a potentially modifiable factor that may have a significant impact on recovery after injury. We sought to assess the association between one's perceived social support (PSS) and physical and mental health outcomes 6 months to 12 months postinjury. METHODS Moderate to severely injured patients admitted to one of three Level I trauma centers were asked to complete a phone-based survey assessing physical and mental health outcomes in addition to return to work and chronic pain 6 months to 12 months postinjury. Patients were also asked to rate the strength of their PSS on a 5-point Likert scale. Multivariate linear and logistic regression models were built to determine the association between PSS and postdischarge outcome metrics. RESULTS Of 907 patients included in this study, 653 (72.0%) identified themselves as having very strong/strong, 182 (20.1%) as average, and 72 (7.9%) as weak/nonexistent PSS. Patients who reported a weak/nonexistent PSS were younger and were more likely to be male, Black, and to have a lower level of education than those who reported a very strong/strong PSS. After adjusting for potential confounders, patients with a weak/nonexistent PSS were more likely to have new functional limitations and chronic pain in addition to being less likely to be back at work/school and being more likely to screen positive for symptoms of posttraumatic stress disorder, depression and anxiety at 6 months to 12 months postinjury than those with a strong/very strong PSS. CONCLUSION Lower PSS is strongly correlated with worse functional and mental health outcome metrics postdischarge. The strength of one's social support network should be considered when trying to identify patients who are at greatest risk for poor postdischarge outcomes after injury. Our data also lend support to creating a system wherein we strive to build a stronger support network for these high-risk individuals. LEVEL OF EVIDENCE Prognostic/epidemiologic, level III.
- Published
- 2021
31. It still hurts! Persistent pain and use of pain medication one year after injury
- Author
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George Kasotakis, Adil H. Haider, Ali Salim, Syeda S. Al Rafai, Deepika Nehra, Constantine S. Velmahos, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, and Shelby Chun Fat
- Subjects
Adult ,Male ,medicine.medical_specialty ,Pain medication ,Logistic regression ,Three level ,03 medical and health sciences ,0302 clinical medicine ,Quality of life ,Risk Factors ,Humans ,Medicine ,Registries ,030212 general & internal medicine ,Aged ,Aged, 80 and over ,Analgesics ,business.industry ,Persistent pain ,Major trauma ,Chronic pain ,030208 emergency & critical care medicine ,General Medicine ,Middle Aged ,medicine.disease ,Drug Utilization ,Identified patient ,Logistic Models ,Treatment Outcome ,Physical therapy ,Wounds and Injuries ,Female ,Surgery ,Chronic Pain ,business ,Follow-Up Studies - Abstract
Background Given the scarce literature data on chronic post-traumatic pain, we aim to identify early predictors of long-term pain and pain medication use after major trauma. Methods Major trauma patients (Injury Severity Score ≥ 9) from three Level I Trauma Centers at 12 months after injury were interviewed for daily pain using the Trauma Quality of Life questionnaire. Multivariate logistic regression models identified patient- and injury-related independent predictors of pain and use of pain medication. Results Of 1238 patients, 612 patients (49%) felt daily pain and 300 patients (24%) used pain medication 1 year after injury. Of a total of 8 independent predictors for chronic pain and 9 independent predictors for daily pain medication, 4 were common (pre-injury alcohol use, pre-injury drug use, hospital stay ≥ 5 days, and education limited to high school). Combinations of independent predictors yielded weak predictability for both outcomes, ranging from 20% to 72%. Conclusions One year after injury, approximately half of trauma patients report daily pain and one-fourth use daily pain medication. These outcomes are hard to predict.
- Published
- 2019
32. Emergency general surgery procedures in hematopoietic stem cell transplant recipients
- Author
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Deepika Nehra, Ali Salim, Sameer A. Hirji, Joaquim M. Havens, Tarsicio Uribe-Leitz, Adil H. Haider, Zara Cooper, Reza Askari, Manuel Castillo-Angeles, Edward J. Kelly, Sharven Taghavi, and Philippe Armand
- Subjects
Adult ,Male ,Bone marrow transplant ,medicine.medical_specialty ,Multivariate analysis ,Lymphoma ,Digestive System Diseases ,Population ,Graft vs Host Disease ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,Acute care surgery ,030212 general & internal medicine ,education ,Digestive System Surgical Procedures ,education.field_of_study ,business.industry ,General surgery ,Hematopoietic Stem Cell Transplantation ,Hematopoietic stem cell ,General Medicine ,Middle Aged ,medicine.disease ,surgical procedures, operative ,Graft-versus-host disease ,medicine.anatomical_structure ,Hematologic Neoplasms ,030220 oncology & carcinogenesis ,Female ,Surgery ,National database ,Emergencies ,business - Abstract
Outcomes of emergency general surgery (EGS) procedures on hematopoietic stem cell transplant (HST) recipients have not been defined in a large, national database. Whether EGS during HST engraftment admission, or in HST patients with graft versus host disease (GVHD) results in worse outcomes is unknown.The National Inpatient Sample (NIS) was examined for patients with a history of BMT between 2001 and 2014.There were 520,000 HST admissions meeting inclusion criteria, of which, 14,143 (2.7%) required EGS. Of those requiring EGS, 378 (2.7%) were during engraftment admission and 13,765 (97.3%) on subsequent admission. For those requiring EGS during subsequent admission, 9,920 (72.1%) had a history of GVHD and 3,845 (27.9%) did not. On multivariate analysis, requirement of EGS was associated with mortality (OR: 1.71, 95%CI: 1.47-1.99, p 0.001). For patients requiring EGS, engraftment admission or GVHD was not associated with mortality.While EGS results in worse survival for the HST population, patients in their engraftment admission do not appear to be at increased mortality risk. In addition, GVHD does not worsen survival.
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- 2019
33. Development and validation of a revised trauma-specific quality of life instrument
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Adil H. Haider, George C. Velmahos, Alexander Toppo, Deepika Nehra, Terri A. deRoon-Cassini, Juan P. Herrera-Escobar, Ali Salim, Syeda S. Al Rafai, George Kasotakis, and Karen J. Brasel
- Subjects
Adult ,Male ,Biopsychosocial model ,Time Factors ,Psychometrics ,Concurrent validity ,Poison control ,Critical Care and Intensive Care Medicine ,Stress Disorders, Post-Traumatic ,03 medical and health sciences ,Injury Severity Score ,0302 clinical medicine ,Quality of life (healthcare) ,Cronbach's alpha ,Humans ,Medicine ,Prospective Studies ,Registries ,Aged ,business.industry ,Reproducibility of Results ,030208 emergency & critical care medicine ,Evidence-based medicine ,Middle Aged ,Health Surveys ,Confirmatory factor analysis ,Quality of Life ,Wounds and Injuries ,Female ,Surgery ,business ,Follow-Up Studies ,Clinical psychology - Abstract
Background The National Academies of Science has called for routine collection of long-term outcomes after injury. One of the main barriers for this is the lack of practical trauma-specific tools to collect such outcomes. The only trauma-specific long-term outcomes measure that applies a biopsychosocial view of patient care, the Trauma Quality-of-Life (T-QoL), has not been adopted because of its length, lack of composite scores, and unknown validity. Our objective was to develop a shorter version of the T-QoL measure that is reliable, valid, specific, and generalizable to all trauma populations. Methods We used two random samples selected from a prospective registry developed to follow long-term outcomes of adult trauma survivors (Injury Severity Score ≥9) admitted to three level I trauma centers. First, we validated the original T-QoL instrument using the 12-Item Short-Form Health Survey (SF-12) version 2.0 and Breslau post-traumatic stress disorder screening (B-PTSD) tools. Second, we conducted a confirmatory factor analysis to reduce the length of the original T-QoL instrument, and using a different sample, we scored and performed internal consistency and validity assessments of the revised T-QoL (RT-QoL) components. Results All components of the original T-QoL were significantly correlated negatively with the B-PTSD and positively with the SF-12 mental and physical composite scores. After confirmatory factor analysis, a three-component structure using 18 items (six items/component) most appropriately represented the data. Each component in the revised instrument demonstrated a high level of internal consistency (Cronbach's α ≥0.8) and correlated negatively with the B-PTSD and positively with the SF-12, demonstrating concurrent validity. In addition, each of the RT-QoL components was able to distinguish between individuals based on their work status, with those who have returned to work reporting better health. Conclusion This more practical RT-QoL measure greatly increases the ability to evaluate long-term outcomes in trauma more efficiently and meaningfully, without sacrificing the validity and psychometric properties of the original instrument. Level of evidence Prognostic and epidemiological, level III.
- Published
- 2019
34. The impact of in-hospital complications on the long-term functional outcome of trauma patients: A multicenter study
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Syeda S. Al Rafai, Adil H. Haider, Kelsey Han, George C. Velmahos, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Jae Moo Lee, Deepika Nehra, Ali Salim, George Kasotakis, Michel Apoj, and Karen J. Brasel
- Subjects
Male ,medicine.medical_specialty ,Activities of daily living ,medicine.medical_treatment ,030230 surgery ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Odds Ratio ,Humans ,Medicine ,Rehabilitation ,business.industry ,Medical record ,Recovery of Function ,Odds ratio ,Confidence interval ,Hospitalization ,Blunt trauma ,030220 oncology & carcinogenesis ,Wounds and Injuries ,Injury Severity Score ,Female ,Surgery ,business ,Complication - Abstract
Background The long-term consequences of in-hospital complications remain largely unknown. We sought to study the effect of complications on the long-term functional outcome of trauma patients. Methods Patients with an Injury Severity Score ≥ 9 admitted to 3, level I trauma centers between 2015 and 2017 were contacted 6 to 12 months postinjury and administered a validated trauma quality-of-life survey, assessing for the presence of any functional limitation. Functional limitation was defined as the inability to perform independently one or more activities of daily living (eg, driving, walking on flat surfaces/upstairs, dressing). Medical records and the trauma registry were reviewed systematically for all patient and injury variables. The occurrence of predefined in-hospital complications (eg, pneumonia, surgical site infection) was recorded. The impact of in-hospital complications on functional limitation was assessed using multivariate logistic regression models. Results Of 1,709 patients, 1,022 completed the study. The mean age was 58 y, 56% were male, 94% had blunt trauma, and the mean Injury Severity Score was 15. A total of 168 patients (16.4%) had a minimum of 1 in-hospital complication and reported significantly more functional limitations in most activities of daily living at 6 to 12 months, compared with those without complications. In multivariable analyses adjusting for confounders, the occurrence of complications was associated with a greater likelihood of functional limitation 6 to 12 months postinjury (odds ratio = 1.82, 95% confidence interval 1.22–2.69, P = .003). Conclusion Trauma patients with in-hospital complications have a worse long-term functional outcome. In addition to prevention of primary complications, more rehabilitation resources should be made available to trauma patients who survive complications.
- Published
- 2019
35. Outcomes of a low-osmolar water-soluble contrast pathway in small bowel obstruction
- Author
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Stephanie Nitzschke, Heather Lyu, Zara Cooper, Naomi Shimizu, Reza Askari, Robert Riviello, Manuel Castillo-Angeles, Deepika Nehra, Ali Salim, Edward J. Kelly, Melanie Bruno, and Joaquim M. Havens
- Subjects
Male ,Radiography, Abdominal ,medicine.medical_specialty ,Iohexol ,Radiography ,media_common.quotation_subject ,Contrast Media ,Length of hospitalization ,Critical Care and Intensive Care Medicine ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,Contrast (vision) ,Intestinal obstruction surgery ,Prospective Studies ,Prospective cohort study ,Aged ,media_common ,business.industry ,Critical pathways ,Historically Controlled Study ,030208 emergency & critical care medicine ,Length of Stay ,Middle Aged ,medicine.disease ,Surgery ,Bowel obstruction ,Treatment Outcome ,Water soluble ,Critical Pathways ,Female ,business ,Intestinal Obstruction - Abstract
Adhesive small-bowel obstruction (SBO) is a common surgical condition accounting for a significant proportion of acute surgical admissions and surgeries. The implementation of a high-osmolar water-soluble contrast challenge has repeatedly been shown to reduce hospital length of stay and possibly the need for surgery in SBO patients. The effect of low-osmolar water-soluble contrast challenge however, is unclear. The aim of this study is to evaluate the outcomes of an SBO pathway including a low-osmolar water-soluble contrast challenge.A prospective cohort of patients admitted for SBO were placed on an evidence-based SBO pathway including low-osmolar water-soluble contrast between January 2017 and October 2018 and were compared with a historical cohort of patients prior to the implementation of the pathway from September 2013 through December 2014. The primary outcome was length of stay less than 4 days with a secondary outcome of failure of nonoperative management.There were 140 patients enrolled in the SBO pathway during the study period and 101 historic controls. The SBO pathway was independently associated with a length of stay less than 4 days (odds ratio, 1.76; 95% confidence interval, 1.03-3.00). Median length of stay for patients that were successfully managed nonoperatively was lower in the SBO pathway cohort compared with controls (3 days vs. 4 days, p = 0.04). Rates of readmission, surgery, and bowel resection were not significantly different between the two cohorts.Implementation of an SBO pathway using a low-osmolarity contrast is associated with decreased hospital length of stay. Rates of readmission, surgery, and need for bowel resection for those undergoing surgery were unchanged. An SBO pathway utilizing low-osmolarity water-soluble contrast is safe and effective in reducing length of stay in the nonoperative management of adhesive small-bowel obstructions.Therapeutic study, level IV.
- Published
- 2019
36. Factors Associated With Long-term Outcomes After Injury
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Adil H. Haider, Syeda S. Al Rafai, George C. Velmahos, George Kasotakis, Michel Apoj, Karen J. Brasel, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Alyssa F. Harlow, Deepika Nehra, and Ali Salim
- Subjects
medicine.medical_specialty ,Activities of daily living ,business.industry ,Major trauma ,MEDLINE ,medicine.disease ,Identified patient ,03 medical and health sciences ,Social support ,0302 clinical medicine ,Quality of life ,030220 oncology & carcinogenesis ,Emergency medicine ,medicine ,Injury Severity Score ,030211 gastroenterology & hepatology ,Surgery ,business ,Cohort study - Abstract
Objective The aim of this study was to determine factors associated with patient-reported outcomes, 6 to 12 months after moderate to severe injury. Summary of background data Due to limitations of trauma registries, we have an incomplete understanding of factors that impact long-term patient-reported outcomes after injury. As 96% of patients survive their injuries, several entities including the National Academies of Science, Engineering and Medicine have called for a mechanism to routinely follow trauma patients and determine factors associated with survival, patient-reported outcomes, and reintegration into society after trauma. Methods Over 30 months, major trauma patients [Injury Severity Score (ISS) ≥9] admitted to 3 Level-I trauma centers in Boston were assessed via telephone between 6 and 12 months after injury. Outcome measures evaluated long-term functional, physical, and mental-health outcomes. Multiple regression models were utilized to identify patient and injury factors associated with outcomes. Results We successfully followed 1736 patients (65% of patients contacted). More than half (62%) reported current physical limitations, 37% needed help for at least 1 activity of daily living, 20% screened positive for posttraumatic stress disorder (PTSD), all SF-12 physical health subdomain scores were significantly below US norms, and 41% of patients who were working previously were unable to return to work. Age, sex, and education were associated with long-term outcomes, while almost none of the traditional measures of injury severity were. Conclusion The long-term sequelae of trauma are more significant than previously expected. Collection of postdischarge outcomes identified patient factors, such as female sex and low education, associated with worse recovery. This suggests that social support systems are potentially at the core of recovery rather than traditional measures of injury severity.
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- 2018
37. A multicenter study of post-traumatic stress disorder after injury: Mechanism matters more than injury severity
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Adil H. Haider, Anupamaa J Seshadri, George C. Velmahos, Deepika Nehra, Syeda S. Al Rafai, Christina Weed, Ali Salim, Alyssa F. Harlow, George Kasotakis, Michel Apoj, Karen J. Brasel, Juan P. Herrera-Escobar, and Haytham M.A. Kaafarani
- Subjects
Adult ,Male ,medicine.medical_specialty ,Logistic regression ,Stress Disorders, Post-Traumatic ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Prevalence ,medicine ,Humans ,Mechanism (biology) ,business.industry ,Traumatic stress ,030208 emergency & critical care medicine ,Middle Aged ,Mental health ,Traumatic injury ,Multicenter study ,030220 oncology & carcinogenesis ,Cohort ,Wounds and Injuries ,Injury Severity Score ,Female ,Surgery ,business ,Boston ,Follow-Up Studies - Abstract
Background Traumatic injury is strongly associated with long-term mental health disorders, but the risk factors for developing these disorders are poorly understood. We report on a multi-institutional collaboration to collect long-term patient-centered outcomes after trauma, including screening for post-traumatic stress disorder. The objective of this study is to determine the prevalence of and risk factors for the development of post-traumatic stress disorder after traumatic injury. Methods Adult trauma patients (aged 18–64) with moderate to severe injuries (Injury Severity Score ≥ 9) admitted to 3 level I trauma centers were screened between 6 and 12 months after injury for post-traumatic stress disorder. Patients were divided by mechanism: fall, road traffic injury, and intentional injury. Multiple logistic regression models were used to determine the association between baseline patient and injury-related characteristics and the development of post-traumatic stress disorder for the overall cohort and by mechanism of injury. Results A total of 450 patients completed the screen. Overall 32% screened positive for post-traumatic stress disorder, but this differed significantly by mechanism, with the lowest being after a fall (25%) and highest after intentional injury (60%). Injury severity was not associated with post-traumatic stress disorder for any group, but lower educational level was associated with post-traumatic stress disorder within all the groups. Only 21% of patients who screened positive for post-traumatic stress disorder were receiving treatment at the time of the survey. Conclusion Post-traumatic stress disorder is common after traumatic injury, and the prevalence varies significantly by injury mechanism but is not associated with injury severity. Only a small proportion of patients who screen positive for post-traumatic stress disorder are currently receiving treatment.
- Published
- 2018
38. Perceived Socioeconomic Status: A Strong Predictor of Long-Term Outcomes After Injury
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Mohamad El Moheb, Kaye Lu, Juan Herrera-Escobar, Claudia P. Orlas, Kerry Breen, Sabrina E. Sanchez, George Velmahos, Haytham M.A. Kaafarani, Ali Salim, and Deepika Nehra
- Subjects
Social Class ,Socioeconomic Factors ,Trauma Centers ,Income ,Educational Status ,Humans ,Surgery ,Chronic Pain - Abstract
Socioeconomic status (SES) is defined as a total measure of an individual's economic or social position in relation to others. Income and educational level are often used as quantifiable objective measures of SES but are inherently limited. Perceived SES (p-SES), refers to an individual's perception of their own SES. Herein, we assess the correlation between objective SES (o-SES) as defined by income and educational level and p-SES after injury and compare their associations with long-term outcomes after injury.Moderate-to-severely injured patients admitted to a Level 1 trauma center were asked to complete a phone-based survey assessing functional and mental health outcomes, social dysfunction, chronic pain, and return to work/school 6-12 mo postinjury. o-SES was determined by income and educational level (low educational level: high school or lower; low income: live in zip code with median income/household lower than the national median). p-SES was determined by asking patients to categorize their SES. The correlation coefficient between o-SES and p-SES was calculated. Multivariate logistic regression models were built to determine the associations between o-SES and p-SES and long-term outcomes.A total of 729 patients were included in this study. Patients who reported a low p-SES were younger, more likely to suffer penetrating injuries, and to have a weak social support network. Twenty-one percent of patients with high income and high educational level classified their p-SES as low or mid-low, and conversely, 46% of patients with low education and low income classified their p-SES as high or mid-high. The correlation coefficient between p-SES and o-SES was 0.2513. After adjusting for confounders, p-SES was a stronger predictor of long-term outcomes, including functional limitations, social dysfunction, mental health outcomes, return to work/school, and chronic pain than was o-SES.Patient-reported p-SES correlates poorly with o-SES indicating that the commonly used calculation of income and education may not accurately capture an individuals' SES. Furthermore, we found p-SES to be more strongly correlated with long-term outcome measures than o-SES. As we strive to improve long-term outcomes after injury, p-SES may be an important variable in the early identification of individuals who are likely to suffer from worse long-term outcomes after injury.
- Published
- 2021
39. Adult survivors of moderate and great complexity congenital heart disease undergoing general surgery procedures: How do they fare?
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Ramsis Ramsis, Manuel Castillo-Angeles, Nael Aldweib, Bethany J. Farr, Alexander R. Opotowsky, Barbara U. Okafor, Nikita Patel, Samuel E. Rice-Townsend, and Deepika Nehra
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Adult ,Heart Defects, Congenital ,Male ,medicine.medical_specialty ,Heart disease ,medicine.medical_treatment ,Coarctation of the aorta ,Young Adult ,medicine ,Humans ,Hospital Mortality ,Survivors ,Complex congenital heart disease ,Aorta ,Tetralogy of Fallot ,business.industry ,General surgery ,General Medicine ,Middle Aged ,medicine.disease ,medicine.anatomical_structure ,Ventricle ,Pulmonary valve ,Cohort ,Surgery ,Cholecystectomy ,Female ,business - Abstract
Background Patients with complex congenital heart disease (CHD) are now commonly surviving well into adulthood. We describe the clinical characteristics and outcomes for a cohort of adult patients with moderate and great complexity CHD undergoing general surgery procedures. Methods The electronic records of two tertiary centers were queried to identify adult patients with moderate and great complexity CHD who underwent a general surgery procedure between 2007 and 2017. Results 118 adult patients were included in the analysis. The mean age was 36 ± 17 years and 49.2% were male. The most common cardiac diagnoses were pulmonary valve anomaly (24.6%), tetralogy of Fallot (18.6%), coarctation of the aorta (15.3%) and common/single ventricle (10.2%). The most common general surgery procedures performed were cholecystectomy (23.7%), herniorrhaphy (23.7%) and colorectal resection (9.3%). In-hospital mortality and morbidity were 2.5% and 11.9%, respectively. Conclusion Adults survivors of moderate and great complexity CHD undergoing common general surgery procedures in this study experienced excellent in-hospital outcomes.
- Published
- 2021
40. The Social Vulnerability Index: A Useful Needs Assessment Tool to Guide Intervention and Prevention Efforts after Injury?
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Ali Salim, Molly P. Jarman, Deepika Nehra, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Ka Man Hau, Sabrina E. Sanchez, Claudia P. Orlas, Tarsicio Uribe-Leitz, and Mohamad El Moheb
- Subjects
Gerontology ,Index (economics) ,business.industry ,Intervention (counseling) ,Needs assessment ,Medicine ,Surgery ,business ,Social vulnerability - Published
- 2021
41. Sex differences in long-term outcomes after traumatic injury: A mediation analysis
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George Kasotakis, Christina Weed, Karen J. Brasel, Mohamad El Moheb, Adil H. Haider, George C. Velmahos, Ali Salim, Deepika Nehra, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Molly P. Jarman, and Anju Ranjit
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Male ,medicine.medical_specialty ,business.industry ,Female sex ,General Medicine ,Middle Aged ,Trauma outcomes ,Posttraumatic stress ,Traumatic injury ,Sex Factors ,Risk Factors ,Internal medicine ,Extremity injury ,Female patient ,Outcome Assessment, Health Care ,medicine ,Long term outcomes ,Humans ,Wounds and Injuries ,Surgery ,Functional status ,Female ,Prospective Studies ,business ,Aged - Abstract
Background We sought to examine the association and potential mediators between sex and long-term trauma outcomes. Methods Moderately-to-severely injured patients admitted to 3 level-1 trauma centers were contacted between 6 and 12-months post-injury to assess for functional limitations, use of pain medications, and posttraumatic stress disorder (PTSD). Multivariable adjusted regression analyses were used to compare long-term outcomes by sex. Potential mediators of the relationship between sex and outcomes was explored using mediation analysis. Results 2607 patients were followed, of which 45% were female. Compared to male, female patients were more likely to have functional limitations (OR: 1.45; 95% CI: 1.31–1.60), take pain medications (OR: 1.17; 95% CI: 1.02–1.38), and screen positive for PTSD (OR: 1.60; 95% CI: 1.46–1.76) post-injury. Age, extremity injury, previous psychiatric illness, and pre-injury unemployment, partially mediated the effect of female sex on long-term outcomes. Conclusions There are significant sex differences in long-term trauma outcomes, which are partially driven by patient and injury-related factors.
- Published
- 2020
42. Rapid ethnographic assessment of the COVID-19 pandemic April 2020 'surge' and its impact on service delivery in an Acute Care Medical Emergency Department and Trauma Center
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Allison Engstrom, Douglas F. Zatzick, Mark Taylor, Deepika Nehra, Kathleen Moloney, Lawrence A. Palinkas, and Lauren K. Whiteside
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Washington ,medicine.medical_specialty ,Service delivery framework ,Attitude of Health Personnel ,Pneumonia, Viral ,infectious diseases ,orthopaedic & trauma surgery ,Betacoronavirus ,Trauma Centers ,Acute care ,medicine ,accident & emergency medicine ,Humans ,Personal protective equipment ,Pandemics ,Qualitative Research ,business.industry ,SARS-CoV-2 ,Public health ,Trauma center ,public health ,COVID-19 ,Emergency department ,General Medicine ,medicine.disease ,Mental health ,Emergency Medicine ,trauma management ,Medicine ,Medical emergency ,adult psychiatry ,business ,Coronavirus Infections ,Emergency Service, Hospital ,Qualitative research - Abstract
ObjectivesAssess the impacts of the COVID-19 pandemic on service delivery by frontline healthcare providers in acute care medical and emergency department settings and identify strategies used to cope with pandemic-related physical and mental health demands.DesignRapid clinical ethnography of patient–provider encounters during an initial pandemic ‘surge’ conducted by a team of clinician–researchers using a structured protocol for qualitative data collection and analysis.SettingLevel 1 trauma centre at Harborview Hospital in Seattle Washington in April 2020.ParticipantsFrontline clinical providers serving as participant observers during performance of their clinical duties recorded observations and summaries of conversations with other providers and patients.ResultsWe identified four different kinds of impacts: procedural, provider, patient and overall. Each impact highlighted two or more levels of a socioecological model of services delivery: (1) the epidemiology of COVID-19, (2) outer setting, (3) inner or organisational setting and (4) individual patient and provider. Despite significant changes in procedures that included COVID-19 screening of all admitted patients, social distancing and use of personal protective equipment, as well as changes in patient and provider behaviour, the overall impact of the pandemic on the emergency department and acute care service delivery was minimal. This is attributed to having a smaller surge than expected, a quick response by the healthcare system to anticipated demands for service delivery and protection of patients and providers, adequate supplies and high provider morale.ConclusionsAlthough limited to one setting in one healthcare system in one community, the findings offer some important lessons for healthcare systems that have yet to be impacted as well as systems that have been more severely impacted. Each of the socioecological framework levels was found to impact service delivery to patients, and variations at each of these levels account for variations in that quality of care globally.
- Published
- 2020
43. Patient-reported Outcomes at 6 to 12 Months Among Survivors of Firearm Injury in the United States
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Adil H. Haider, Justin C. McCarty, Juan P. Herrera-Escobar, Deepika Nehra, Elzerie de Jager, Stuart R. Lipsitz, and Ali Salim
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Adult ,Male ,medicine.medical_specialty ,Activities of daily living ,Adolescent ,Population ,Psychological intervention ,MEDLINE ,03 medical and health sciences ,0302 clinical medicine ,Quality of life ,Trauma Centers ,Medicine ,Humans ,Patient Reported Outcome Measures ,Prospective Studies ,Registries ,Survivors ,education ,education.field_of_study ,business.industry ,Accidents, Traffic ,Odds ratio ,Middle Aged ,Mental health ,Confidence interval ,030220 oncology & carcinogenesis ,Emergency medicine ,030211 gastroenterology & hepatology ,Surgery ,Female ,Wounds, Gunshot ,business ,Boston - Abstract
Objective Assess outcomes in survivors of firearm injuries after 6 to 12 months and compared them with a similarly injured trauma population. Background For every individual in the United States who died of a firearm injury in 2017, three survived, living with the burden of their injury. Current firearm research largely focuses on mortality and short-term health outcomes, while neglecting the long-term consequences. Methods We contacted adult patients with a moderate-to-severe injury from a firearm or motor vehicle crash (MVC) treated at 3 level I trauma centers in Boston between 2015 and 2018. Patients were contacted 6 to 12 months postinjury to measure: presence of daily pain; screening for post-traumatic stress disorder (PTSD); new functional limitations; return to work; and physical and mental health-related quality of life. We matched each firearm injury patient to MVC patients using Coarsened Exact Matching. Adjusted Generalized Linear Models were used to compare matched patients. Results Of 177 eligible firearm injury survivors, 100 were successfully contacted and 63 completed the study. Among them, 67.7% reported daily pain, 53.2% screened positive for PTSD, 38.7% reported a new functional limitation in an activity of daily living, and 59.1% have not returned to work. Compared with population norms, overall physical and mental health-related quality of life was significantly reduced among firearm injury survivors. Compared with matched MVC survivors (n = 255), firearm injury survivors were significantly more likely to have daily pain [adjusted odds ratio (OR) 2.30, 95% confidence interval (CI) 1.08-4.87], to screen positive for PTSD (adjusted OR 3.06, 95% CI 1.42-6.58), and had significantly worse physical and mental health-related quality of life. Conclusions This study highlights the need for targeted long-term follow-up care, physical rehabilitation, mental health screening, and interventions for survivors of firearm violence.
- Published
- 2020
44. Long-term patient-reported outcome measures after injury: National Trauma Research Action Plan (NTRAP) scoping review protocol
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Michelle A. Price, Mahin Janjua, Claudia P. Orlas, Eileen M. Bulger, Deepika Nehra, Muhammad Abdullah-Arain, Manuel Castillo-Angeles, Samia Y Osman, Molly P. Jarman, Adil H. Haider, Emma Reidy, and Juan P. Herrera-Escobar
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Population ,Delphi method ,outcome assessment, healthcare ,wounds and injuries ,Critical Care and Intensive Care Medicine ,03 medical and health sciences ,0302 clinical medicine ,Quality of life (healthcare) ,Health care ,Medicine ,030212 general & internal medicine ,education ,patient-reported outcome measures ,education.field_of_study ,Descriptive statistics ,business.industry ,Brief Report ,030208 emergency & critical care medicine ,medicine.disease ,Systematic review ,Action plan ,Surgery ,Patient-reported outcome ,Medical emergency ,business - Abstract
BackgroundA significant proportion of patients who survive traumatic injury continue to suffer impaired functional status and increased mortality long after discharge. However, despite the need to improve long-term outcomes, trauma registries in the USA do not collect data on outcomes or care processes after discharge. One of the main barriers is the lack of consensus regarding the optimal outcome metrics.ObjectivesTo describe the methodology of a scoping review evaluating current evidence on the available measures for tracking functional and patient-reported outcomes after injury. The aim of the review was to identify and summarize measures that are being used to track long-term functional recovery and patient-reported outcomes among adults after injury.MethodsA systematic search of PubMed and Embase will be performed using the search terms for the population (adult trauma patients), type of outcomes (long-term physical, mental, cognitive, and quality of life), and measures available to track them. Studies identified will be reviewed and assessed for relevance by at least two reviewers. Data will be extracted and summarized using descriptive statistics and a narrative synthesis of the results. This protocol is being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.DisseminationThis scoping review will provide information regarding the currently available metrics for tracking functional and patient-reported outcomes after injury. The review will be presented to a multi-disciplinary stakeholder group that will evaluate these outcome metrics using an online Delphi approach to achieve consensus as part of the development of the National Trauma Research Action Plan (NTRAP). The results of this review will be presented at relevant national surgical conferences and published in peer-reviewed scientific journals.
- Published
- 2020
45. How Should a Surgeon and Anesthesiologist Cooperate During Intraoperative Cardiac Arrest?
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Deepika Nehra and Joshua S. Jolissaint
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Surgeons ,medicine.medical_specialty ,Health (social science) ,business.industry ,Health Policy ,Incidence (epidemiology) ,General surgery ,Incidence ,Intraoperative cardiac arrest ,Anesthesiologists ,Heart Arrest ,Issues, ethics and legal aspects ,Perioperative care ,cardiovascular system ,Medicine ,Humans ,Anesthesia ,business ,Noncardiac surgery ,Cardiac arrest during surgery - Abstract
Surgeons and anesthesiologists each have a unique sense of duty and responsibility to patients throughout all phases of perioperative care. Intraoperative cardiac arrest during elective, noncardiac surgery is rare, with an incidence between 0.8 to 4.3 per 10 000 cases. Fortunately, patients who suffer cardiac arrest during surgery are more likely to survive than patients who suffer cardiac arrest in other settings. This article considers factors that have been shown to influence outcomes after intraoperative cardiac arrest and offers a framework for analyzing and discussing these clinically, ethically, and emotionally complex cases.
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- 2020
46. Experiences and Insights from the Early US COVID-19 Epicenter: A Rapid Assessment Procedure Informed Clinical Ethnography Case Series
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Mary Lou Walen, Hannah Scheuer, Douglas F. Zatzick, Allison Engstrom, Merritt Schreiber, Lauren K. Whiteside, Frederick P. Rivara, Kathleen Moloney, and Deepika Nehra
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Male ,History ,Criminology ,Medical and Health Sciences ,01 natural sciences ,0302 clinical medicine ,Pandemic ,80 and over ,Viral ,030212 general & internal medicine ,Community Health Services ,Randomized Controlled Trials as Topic ,Aged, 80 and over ,Patient care team ,Gunshot ,Accidents, Traffic ,Middle Aged ,Psychiatry and Mental health ,Wounds ,Female ,Coronavirus Infections ,Multiple ,Femoral Fractures ,Washington ,2019-20 coronavirus outbreak ,Coronavirus disease 2019 (COVID-19) ,Adolescent ,Fractures, Multiple ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,Clinical Trials and Supportive Activities ,Pneumonia, Viral ,Quadriplegia ,Risk Assessment ,Peer Group ,03 medical and health sciences ,Betacoronavirus ,Clinical Research ,Cultural ,Traffic ,Humans ,0101 mathematics ,Pandemics ,Anthropology, Cultural ,Spinal Cord Injuries ,Aged ,Patient Care Team ,Infection Control ,Clinical ethnography ,Primary Health Care ,SARS-CoV-2 ,Prevention ,Psychology and Cognitive Sciences ,010102 general mathematics ,COVID-19 ,Pneumonia ,Rapid assessment ,Good Health and Well Being ,Accidents ,Anthropology ,Epicenter ,Wounds and Injuries ,Wounds, Gunshot ,Fractures - Abstract
ObjectiveThe Coronavirus disease (COVID-19) outbreak has evolved into a pandemic crisis, with King County in Washington State emerging as the early US epicenter. A literature review revealed few reports providing front-line clinical and research teams guidance related to multilevel, rapidly evolving COVID-19 directives.MethodThe Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) method was used to develop a clinical case series and conduct participant observation during an ongoing comparative effectiveness trial of peer-integrated, patient-centered interventions after traumatic injury. Participants were patients enrolled in the intervention arm of the ongoing trial, as well as front-line clinicians, patient peer interventionists, and clinical research team members implementing the trial. All participants were exposed to the Washington State COVID-19 outbreak.ResultsPrimary and secondary COVID-19 prevention strategies were feasibly integrated into ongoing care coordination and behavioral interventions for at-risk patients. Beyond the compilation of case studies, as an iterative method, RAPICE data collection naturalistically evolved to include observations of intervention team activity occurring within the larger pandemic epicenter context. A daily clinical research team huddle that flexibly accommodated virtual participation was also feasibly implemented.ConclusionsPrimary and secondary COVID-19 prevention strategies can be feasibly integrated into ongoing clinical interventions during the pandemic. Routine, proactive clinical and research team communication that transparently addresses ethical tensions and health-sustaining activities may promote well-being for providers grappling with rapidly evolving pandemic directives. Proactive assessments of individual provider vulnerabilities for severe COVID-19 related respiratory illness may also be a crucial element of the health care system pandemic responses.
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- 2020
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47. Traumatic Brain Injury: Does Admission Service Matter?
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Deepika Nehra, Nikita Patel, Leo Andrew Benedict, Reza Askari, Manuel Castillo-Angeles, Ali Salim, Ramsis Ramsis, and Anupamaa Seshadri
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Male ,medicine.medical_specialty ,Traumatic brain injury ,medicine.medical_treatment ,03 medical and health sciences ,0302 clinical medicine ,Patient Admission ,Seizures ,Brain Injuries, Traumatic ,Medicine ,Humans ,Craniotomy ,Aged ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Retrospective cohort study ,Venous Thromboembolism ,Middle Aged ,medicine.disease ,030220 oncology & carcinogenesis ,Chemoprophylaxis ,Cohort ,Emergency medicine ,030211 gastroenterology & hepatology ,Surgery ,Body region ,Female ,Neurosurgery ,business ,Trauma surgery - Abstract
Background Traumatic brain injury (TBI) is common, and significant institutional variation exists with regards to structure and processes of care. Affected patients may be admitted to one of several different services, and this may drive differential care and outcomes. We sought to evaluate differential care and outcomes for patients with isolated mild-to-moderate traumatic brain injury based on admission service. Materials and methods This is a single-institution retrospective study of all adult (≥18 y old) patients admitted with isolated TBI (AIS ≤1 in all other body regions) over a 3-year period (6/2015-6/2018). Patients who underwent neurosurgical intervention (craniectomy/craniotomy) and those with a head AIS ≥4 were excluded. Patients were assigned to one of three groups based upon admission service: Trauma Surgery, Neurology/Medicine or Neurosurgery. Outcomes evaluated included in-hospital mortality and markers of differential care. We performed multivariate analyses adjusting for patient demographics and clinical characteristics. Results A total of 401 isolated mild-to-moderate TBI patients were identified. Overall mortality was 1.7%. Adjusted multivariate logistic regression analysis demonstrated no difference in mortality. Patients admitted to Neurosurgery underwent more repeat head CTs and were more likely to receive antiseizure medication in the absence of seizure activity, and those admitted to Neurology/Medicine were less likely to receive venous thromboembolism chemoprophylaxis compared to those admitted to Trauma Surgery. Conclusions We identify several important metrics of variation in care received by patients with an isolated mild-to-moderate TBI based upon admission service. These findings deserve further study, and this study may lay the foundation for future efforts at protocolizing care in an evidence-based fashion for this patient cohort.
- Published
- 2020
48. Reduced chronic pain: Another benefit of recovery at an inpatient rehabilitation facility over a skilled nursing facility?
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Deepika Nehra, David Blake, Ali Salim, George Kasotakis, Kelsey Han, Juan P. Herrera-Escobar, Haytham M.A. Kaafarani, Adil H. Haider, George C. Velmahos, and Alexander Toppo
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Adult ,Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Analgesic ,Rehabilitation Centers ,03 medical and health sciences ,0302 clinical medicine ,Long term outcomes ,Medicine ,Humans ,Aged ,Skilled Nursing Facilities ,Aged, 80 and over ,Rehabilitation ,business.industry ,Chronic pain ,030208 emergency & critical care medicine ,General Medicine ,Middle Aged ,medicine.disease ,Inpatient rehabilitation facility ,030220 oncology & carcinogenesis ,Physical therapy ,Wounds and Injuries ,Surgery ,Female ,Skilled Nursing Facility ,Chronic Pain ,business - Abstract
Background We sought to compare outcomes 6–12 months post-injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF). Methods Trauma patients admitted to 3 Level-I trauma centers were interviewed to evaluate the presence of daily pain requiring medication, functional outcomes, and physical and mental health-related quality-of-life at 6–12 months post-injury. Inverse-probability-of-treatment-weighting (IPTW)–adjusted analyses were performed to compare outcomes between patients who were discharged to IRF vs SNF. Results A total of 519 patients were included: 389 discharged to IRFs and 130 to SNFs. In adjusted analyses, IRF was associated with a significant reduction in the likelihood of chronic pain after injury (28.3% vs. 44.7%; OR:0.49; 95% CI, 0.26–0.91; P = .02). However, there were no significant differences in functional outcome or SF-12 composite scores between groups. Conclusion Our findings suggest that injured patients discharged to an IRF as compared to a SNF had less chronic pain and analgesic use.
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- 2020
49. Development of a Comprehensive Trauma Training Curriculum for the Resource-Limited Environment
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Susan M. Briggs, Geoffrey A. Anderson, Lenka Ilcisin, Noralis Portal Benitez, Katherine Albutt, Deepika Nehra, and Peter Kayima
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Male ,Referral ,Cost-Benefit Analysis ,education ,Medically Underserved Area ,Survey result ,Subspecialty ,Risk Assessment ,Statistics, Nonparametric ,Education ,Likert scale ,03 medical and health sciences ,0302 clinical medicine ,Curriculum development ,Humans ,Medicine ,Uganda ,030212 general & internal medicine ,Developing Countries ,Poverty ,Training curriculum ,business.industry ,Medical school ,030208 emergency & critical care medicine ,medicine.disease ,Traumatology ,Education, Medical, Graduate ,Health Resources ,Female ,Surgery ,Clinical Competence ,Curriculum ,Medical emergency ,Emergencies ,business ,Limited resources - Abstract
Objective The goal of this project was to create a multitiered trauma training curriculum that was designed specifically for the low-resource setting. Design We developed 2 courses designed to teach principles and skills necessary for trauma care. The first course, “Emergency Ward Management of Trauma (EWMT),” is designed to teach interns the initial assessment and stabilization of trauma patients in the emergency ward. The second course for mid-level surgical residents, “Surgical Techniques and Repairs in Trauma for the Low-resource Environment” (STaRTLE), is a cadaver-based operative trauma course designed to teach surgical exposures and techniques. The courses were rolled out at Mbarara Regional Referral Hospital in the low-income country of Uganda. Precourse and postcourse tests and surveys were administered. Setting This study took place at Mbarara Regional Referral Hospital (MRRH). This is a hospital in southwest Uganda with a subspecialty care, a medical school, nursing school, and multiple residency programs. Participants Students in the EWMT course were interns at MRRH. After 1 year of training, most of these interns will become medical officers as the only provider at a district hospital in Uganda. The students in the STARTLE course were second-year residents in the general surgery program at MRRH. Results Scores on knowledge based tests improved significantly with both courses. Survey results from the EWMT course suggest that participants feel better prepared to care for the injured patient (median Likert [IQR]: 5.0 [5.0-5.0]) and that their practice improved (5.0 [5.0-5.0]). Similarly, following the STaRTLE course we found participants felt significantly more comfortable with performing 20 of the 22 operative procedures taught. Conclusions These courses represent a feasible, cost-effective, and resource appropriate trauma education curriculum that if standardized and implemented may improve trauma care and outcomes in the resource-limited setting.
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- 2018
50. Proceedings from the Consensus Conference on Trauma Patient-Reported Outcome Measures
- Author
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Barbara A. Gaines, Helen Burstin, Kathleen Keavany, James R. Ficke, Stephanie Bonne, Nicole S. Gibran, Mary E. Fallat, Deborah M. Stein, Joseph Cuschieri, Hiba Ezzeddine, Eileen M. Bulger, Brian Brighton, Martin D. Zielinski, Anna N. Miller, C. William Schwab, Ronald M. Stewart, Heidi Hotz, William L. Thomas, Eric Chaney, Rochelle A. Dicker, Melanie Neal, Cate Miller, Pam Bixby, Babak Sarani, Peter Yonclas, David S. Morris, Michelle A. Price, Rob Winfield, Elliott R. Haut, Juan P. Herrera-Escobar, H. Gerry Taylor, Christopher J. Burns, Mark Sochor, David M. Livingston, Nomi C Levy-Carrick, David O. Okonkwo, Adil H. Haider, Belinda Gabbe, Bhavin Patel, Travis M. Polk, Deepika Nehra, Haris Subacius, Kevin C. Chung, Bob Gfeller, Amy K. Wagner, Craig D. Newgard, Joseph T. Giacino, Christopher Michetti, Avery B. Nathens, Stephanie Nitzschke, Michelle Caldwell, Terri deRoon-Cassine, Bellal Joseph, Douglas F. Zatzick, Bindi Naik-Mathuria, Mark D. Cipolle, Brad G. Kurowski, Jason Hendrix, Karen J. Brasel, Erin C. Hall, Lillian S. Kao, Samuel P. Mandell, Ben L. Zarzaur, Joseph V. Sakran, Mark J. Seamon, Frederick P. Rivara, Dagmar Amtmann, Chris Hoeft, Gerard A. Gioia, Geoffrey T. Manley, and Randall S. Burd
- Subjects
Patient-Reported Outcomes Measurement Information System ,medicine.medical_specialty ,Trauma patient ,Short Message Service ,SF-36 ,business.industry ,Consensus conference ,Outcome measures ,Prom ,Recovery of Function ,United States ,EQ-5D ,Physical therapy ,Quality of Life ,Medicine ,Humans ,Wounds and Injuries ,Surgery ,Patient Reported Outcome Measures ,business - Published
- 2019
Catalog
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