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Shock index, pediatric age adjusted (SIPA), has been widely applied in pediatric trauma but has limited precision because of the reference ranges used in its derivation. We hypothesized that a pediatric shock index (PSI) equation based on age-based vital signs would outperform SIPA.A retrospective cohort of trauma patients aged 1 to 18 years from Trauma Quality Programs - Participant Use File 2010 to 2018 was performed. A random 70% training subset was used to derive Youden index-optimizing shock index (SI) cutoffs by age for blood transfusion within 4 hours. We used linear regression to derive equations representing the PSI cutoff for children 12 years or younger and 13 years or older. For children 13 years or older, the well-established SI of 0.9 remained optimal, consistent with SIPA and other indices. For children 12 years or younger in the 30% validation subset, we compared our age-based PSI to SIPA as predictors of early transfusion, mortality, pediatric intensive care unit admission, and injury severity score of ≥25. For bedside use, a simplified "rapid" pediatric shock index (rPSI) equation was also derived and compared with SIPA.A total of 439,699 patients aged 1 to 12 years met the inclusion criteria with 2,718 (1.3% of those with available outcome data) requiring transfusion within 4 hours of presentation. In the validation set, positive predictive values for early transfusion were higher for PSI (8.3%; 95% confidence interval [CI], 7.5-9.1%) and rPSI (6.3%; 95% CI, 5.7-6.9%) than SIPA (4.3%; 95% CI, 3.9-4.7%). For early transfusion, negative predictive values for both PSI (99.3%; 95% CI, 99.2-99.3%) and rPSI (99.3%; 95% CI, 99.2-99.4%) were similar to SIPA (99.4%; 95% CI, 99.3-99.4%).We derived the PSI and rPSI for use in pediatric trauma using empiric, age-based SI cutoffs. The PSI and rPSI achieved higher positive predictive values and similar negative predictive values to SIPA in predicting the need for early blood transfusion and mortality.Prognostic/Epidemiological; level III.

To examine the diversity, equity, and inclusion landscape in academic trauma surgery and the EAST organization.In 2019, the Eastern Association for the Surgery of Trauma (EAST) surveyed its members on equity and inclusion in the #EAST4ALL survey and assessed leadership representation. We hypothesized that women and surgeons of color (SOC) are underrepresented as EAST members and leaders.Survey responses were analyzed post-hoc for representation of females and SOC in academic appointments and leadership, EAST committees, and the EAST board, and compared to the overall respondent cohort. EAST membership and board demographics were compared to demographic data from the Association of American Medical Colleges.Of 306 respondents, 37.4% identified as female and 23.5% as SOC. There were no significant differences in female and SOC representation in academic appointments and EAST committees compared to their male and white counterparts. In academic leadership, females were underrepresented (p0.0001) while SOC were not (p=0.08). Both females and SOC were underrepresented in EAST board membership (p=0.002 and p=0.043, respectively). Of EAST's 33 presidents, three have been white women (9%), two have been Black, non-African American men (6%), and 28 (85%) have been white men. When compared to 2017 AAMC data, women are well-represented in EAST's 2020 membership (p0.0001) and proportionally represented on EAST's 2019-2020 board (p0.05).The #EAST4ALL survey suggests that women and SOC may be underrepresented as leaders in academic trauma surgery. However, lack of high-quality demographic data makes evaluating representation of structurally marginalized groups challenging. National trauma organizations should elicit data from their members to re-assess and promote the diversity landscape in trauma surgery.

Gun violence is an epidemic that affects hundreds of thousands of Americans each year. Despite gun violence being disproportionately more lethal than other leading causes of trauma, there is a dearth of research being carried out on its root causes and prevention strategies. For the past 20 years, lobbying and politics have interfered with the forward progress of gun violence research. Physicians have a history of producing actionable public-health change and have an ethical obligation to fight for the research that will benefit their patients.

BACKGROUND There are no national studies of nonelective readmissions after emergency general surgery (EGS) diagnoses that track nonindex hospital readmission. We sought to determine the rate of overall and nonindex hospital readmissions at 30 and 90 days after discharge for EGS diagnoses, hypothesizing a significant portion would be to nonindex hospitals. METHODS The 2013 to 2014 Nationwide Readmissions Database was queried for all patients 16 years or older admitted with an EGS primary diagnosis and survived index hospitalization. Multivariable logistic regression identified risk factors for nonelective 30- and 90-day readmission to index and nonindex hospitals. RESULTS Of 4,171,983 patients, 13% experienced unplanned readmission at 30 days. Of these, 21% were admitted to a nonindex hospital. By 90 days, 22% experienced an unplanned readmission, of which 23% were to a nonindex hospital. The most common reason for readmission was infection. Publicly insured or uninsured patients accounted for 67% of admissions and 77% of readmissions. Readmission predictors at 30 days included leaving against medical advice (odds ratio [OR], 2.51 [2.47-2.56]), increased length of stay (4-7 days: OR, 1.42 [1.41-1.43]; >7 days: OR, 2.04 [2.02-2.06]), Charlson Comorbidity Index ≥2 (OR, 1.72 [1.71-1.73]), public insurance (Medicare: OR, 1.45 [1.44-1.46]; Medicaid: OR, 1.38 [1.37-1.40]), EGS patients who fell into the "Other" surgical category (OR, 1.42 [1.38-1.48]), and nonroutine discharge. Risk factors for readmission remained consistent at 90 days. CONCLUSION Given that nonindex hospital EGS readmission accounts for nearly a quarter of readmissions and often related to important benchmarks such as infection, current EGS quality metrics are inaccurate. This has implications for policy, benchmarking, and readmission reduction programs. LEVEL OF EVIDENCE Epidemiological study, level III.

The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma.While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field.We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners.Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level.Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

Child abuse is a major cause of childhood injury, morbidity, and death. There is a paucity of data on the practice of abuse interventions among this vulnerable population. The aim of our study was to identify the factors associated with interventions for child abuse on a national scale.Retrospective analysis of 2017 to 2018 American College of Surgeons (ACS) Pediatric Trauma Quality Improvement Program (TQIP). All children presenting with suspected/confirmed child abuse and an abuse report filed were included. Patients with missing information regarding abuse interventions were excluded. Outcomes were abuse investigations initiated among those with abuse reports, and change of caregiver at discharge among survivors with an investigation initiated. Multivariable regression analyses were performed.A total of 7774 child abuse victims with an abuse report were identified. The mean age was 5±5 years, 4221 (54%) patients were White, 2297 (30%) Black, 1543 (20%) Hispanic, and 5298 (68%) had government insurance. The most common mechanism was blunt (63%), followed by burns (10%) and penetrating (10%). The median Injury Severity Score was 5 (1-12). The most common form of abuse was physical (92%), followed by neglect (6%), sexual (3%), and psychological (0.1%). The most common perpetrator of abuse was a care provider/teacher (49.5%), followed by a member of the immediate family (30.5%), or a member of the extended/step/foster family (20.0%). Overall, 6377 (82%) abuse investigations were initiated for those with abuse reports. Of these, 1967 (33%) resulted in a change of caregiver. Black children were more likely to have abuse investigated, and Black and Hispanic children were more likely to experience change of caregiver after investigations, while privately insured children were less likely to experience both.Significant racial, ethnic, and socioeconomic disparities exist in the nationwide management of child abuse. Further studies are strongly warranted to understand contributing factors and possible strategies to address them.Level III-therapeutic/care management.

Trauma-informed care (TIC) is a set of principles and practices designed to improve the ways professionals treat people who have been traumatized. This study reviews fundamental concepts of TIC and applies them to the work of surgeons. TIC is described in relation to fundamental medical ethical concepts, and evidence for TIC-based intervention is reviewed. Implementation of TIC in medical education is also described, and recommendations for practice changes are made.

BACKGROUND The equivalent Injury Severity Score (ISS) cutoffs for severe trauma vary between adult (ISS, >16) and pediatric (ISS, >25) trauma. We hypothesized that a novel injury severity prediction model incorporating age and mechanism of injury would outperform standard ISS cutoffs. METHODS The 2010 to 2016 National Trauma Data Bank was queried for pediatric trauma patients. Cut point analysis was used to determine the optimal ISS for predicting mortality for age and mechanism of injury. Linear discriminant analysis was implemented to determine prediction accuracy, based on area under the curve (AUC), of ISS cutoff of 25 (ISS, 25), shock index pediatric adjusted (SIPA), an age-adjusted ISS/abbreviated Trauma Composite Score (aTCS), and our novel Trauma Composite Score (TCS) in blunt trauma. The TCS consisted of significant variables (Abbreviated Injury Scale, Glasgow Coma Scale, sex, and SIPA) selected a priori for each age. RESULTS There were 109,459 blunt trauma and 9,292 penetrating trauma patients studied. There was a significant difference in ISS (blunt trauma, 9.3 ± 8.0 vs. penetrating trauma, 8.0 ± 8.6; p < 0.01) and mortality (blunt trauma, 0.7% vs. penetrating trauma, 2.7%; p < 0.01). Analysis of the entire cohort revealed an optimal ISS cut point of 25 (AUC, 0.95; sensitivity, 0.86; specificity, 0.95); however, the optimal ISS ranged from 18 to 25 when evaluated by age and mechanism. Linear discriminant analysis model AUCs varied significantly for each injury metric when assessed for blunt trauma and penetrating trauma (penetrating trauma-adjusted ISS, 0.94 ± 0.02 vs. ISS 25, 0.88 ± 0.02 vs. SIPA, 0.62 ± 0.03; p < 0.001; blunt trauma-adjusted ISS, 0.96 ± 0.01 vs. ISS 25, 0.89 ± 0.02 vs. SIPA, 0.70 ± 0.02; p < 0.001). When injury metrics were assessed across age groups in blunt trauma, TCS and aTCS performed the best. CONCLUSION Current use of ISS in pediatric trauma may not accurately reflect injury severity. The TCS and aTCS incorporate both age and mechanism and outperform standard metrics in mortality prediction in blunt trauma. LEVEL OF EVIDENCE Retrospective review, level IV.

Background Inequity exists in surgical training and the workplace. The Eastern Association for the Surgery of Trauma (EAST) Equity, Quality, and Inclusion in Trauma Surgery Ad Hoc Task Force (EAST4ALL) sought to raise awareness and provide resources to combat these inequities. Methods A study was conducted of EAST members to ascertain areas of inequity and lack of inclusion. Specific problems and barriers were identified that hindered inclusion. Toolkits were developed as resources for individuals and institutions to address and overcome these barriers. Results Four key areas were identified: (1) harassment and discrimination, (2) gender pay gap or parity, (3) implicit bias and microaggressions, and (4) call-out culture. A diverse panel of seven surgeons with experience in overcoming these barriers either on a personal level or as a chief or chair of surgery was formed. Four scenarios based on these key areas were proposed to the panelists, who then modeled responses as allies. Conclusion Despite perceived progress in addressing discrimination and inequity, residents and faculty continue to encounter barriers at the workplace at levels today similar to those decades ago. Action is needed to address inequities and lack of inclusion in acute care surgery. The EAST is working on fostering a culture that minimizes bias and recognizes and addresses systemic inequities, and has provided toolkits to support these goals. Together, we can create a better future for all of us.

(1) To identify the factors predicting arterial extravasation in pelvic trauma and (2) to assess the efficacy of preperitoneal pelvic packing (PPP) in controlling arterial hemorrhage. Institutional review board approved the retrospective study of 139 consecutive pelvic trauma patients who underwent angiographic intervention with or without prior PPP between January 2011 and December 2016. Patient demographics and presenting characteristics were recorded. Both groups of patients were combined for analysis of predictors for arterial extravasation using univariate logistic regression followed by multivariate logistic regression. Significance level was defined as p < 0.05. Forty-nine out of 139 patients had PPP prior to pelvic angiogram. Embolization was performed in 85 (61.2%) patients and the technical and clinical success rate was 100%. Sixty-nine (49.7%) patients had unstable Young-Burgess (Y&B) type fractures, of which 58% had arterial hemorrhage compared with 38.6% of those with stable Y&B fractures (p = 0.02). Of the patients who had PPP prior to angiogram, 28(57.1%) continued to have arterial extravasation on subsequent angiography. Unstable Y&B type fractures are independent predictors of arterial hemorrhage (OR 2.3, 95%CI 1.1 to 4.7, p = 0.02). Unstable Y&B type pelvic fractures are predictors of arterial extravasation. PPP alone is not effective for arterial hemorrhage control in pelvic trauma. Angiographic intervention remains a minimally invasive and definitive treatment of arterial hemorrhage from pelvic trauma. • Unstable Young-Burgess pelvic fractures are predictors of arterial hemorrhage in pelvic trauma. • Pelvic angiography and embolization should precede PPP wherever feasible.

The American Medical Association recently declared homicides of transgender individuals an epidemic. However, transgender homicide victims are often classified as nontransgender. Our objective was to describe existing data and coding of trans (i.e., transgender) victims and to examine the risk factors for homicides of trans people relative to nontrans people across the United States.A retrospective review of the Centers for Disease Control and Prevention's National Violent Death Reporting System for the years 2003-2018 identified victims defined as transgender either through the "transgender" variable or narrative reports. Fisher's exact tests and logistic regression models were run to compare the demographics of trans victims to those not identified as trans.Of the 147 transgender victims identified, 14.4% were incorrectly coded as nontrans despite clear indication of trans status in the narrative description, and 6% were coded as hate crimes. Relative to nontrans victims, trans victims were more frequently Black (54.4% versus 40.7%, P = 0.001), had a mental health condition (26.5% versus 11.3%, P 0.001), or reported being a sex worker (9.5% versus 0.2%, P 0.001). There were disproportionately few homicides of transgender people in the South (13.6% of trans victims versus 29.1% of nontrans victims, P 0.001). Conversely, the West and Midwest accounted for a higher-than-expected proportion of trans victims relative to nontrans victims (23.1% of trans victims versus 16.2% of nontrans victims, P = 0.03; 24.5% of trans victims versus 16.8% of nontrans victims, P = 0.02, respectively).Though the murder of transgender individuals is a known public health crisis, inconsistencies still exist in the assessment and reporting of transgender status. Further, these individuals were more likely to have multiple distinct vulnerabilities. These findings provide important information for injury and violence prevention researchers to improve reporting of transgender status in the medical record and local trauma registries.

Key Points Question Are there associations between the COVID-19 stay-at-home order issued March 2020 in Chicago, Illinois, and the rate of domestic violence (DV) police reporting and resource availability? Findings In this cohort study of 77 Chicago community areas, the stay-at-home order was associated with a decrease in the rate of DV police reports by 21.8 crimes per 100 000 persons per month relative to the same months in 2019, a finding observed largely in Black communities, with no significant change in White communities. Resource availability decreased by 5.1 resources per 100 000 persons. Meaning The decreased rate of DV police reports during the stay-at-home order, especially in Black majority communities, may be due to decreased DV incidence or exacerbated underreporting; resource availability also decreased on the predominantly Black south side of Chicago., Importance Domestic violence (DV) has become a growing public health concern during the COVID-19 pandemic because individuals may be sheltering in place with abusers and facing mounting economic and health-related stresses. Objective To analyze associations of the 2020 COVID-19 stay-at-home (SH) order with DV police reporting and resource availability, including differences by community area racial/ethnic composition. Design, Setting, and Participants This longitudinal cohort study assessed DV police reports (January-June 2020) obtained from the Chicago, Illinois, Police Department and DV resource availability (March and August 2020) obtained from the NowPow community resource database, both for 77 community areas in Chicago. Data were analyzed July through December 2020. Exposures The COVID-19 SH order effective March 21, 2020. Main Outcomes and Measures Monthly rates of DV police reports and DV resource availability per 100 000 persons. Results Of 77 community areas in Chicago, 28 (36.4%) were majority Black, 19 (24.7%) majority Hispanic/Latinx, 18 (23.4%) majority White, and 12 (15.6%) a different or no majority race/ethnicity, representing an estimated population of 2 718 555 individuals. For each community area, the SH order was associated with a decrease in the rate of DV police reports by 21.8 (95% CI, −30.48 to −13.07) crimes per 100 000 persons per month relative to the same months in 2019. Compared with White majority community areas, Black majority areas had a decrease in the rate of DV police reports by 40.8 (95% CI, −62.93 to −18.75) crimes per 100 000 persons per month relative to the same months in 2019. The SH order was also associated with a decrease in DV resource availability at a rate of 5.1 (95% CI, −7.55 to −2.67) resources per 100 000 persons, with the largest decreases for mental health (−4.3 [95% CI, −5.97 to −2.66] resources per 100 000 persons) and personal safety (−2.4 [95% CI, −4.40 to −0.41] resources per 100 000 persons). The Black majority south side of Chicago had a larger decrease in resource availability (−6.7 [95% CI, −12.92 to −0.46] resources per 100 000 persons) than the White majority north side. Conclusions and Relevance In this longitudinal cohort study, the rate of DV police reports decreased after the SH order was implemented in Chicago. This decrease was largely observed in Black majority communities, whereas there was no significant change in White majority communities. These findings may reflect decreased DV incidence but may also reflect an exacerbation of underreporting. In addition, DV resource availability decreased disproportionately on the predominantly Black south side of Chicago., This cohort study assesses whether a COVID-19 stay-at-home order was associated with changes in police report rates or domestic violence resource availability that differed by racial/ethnic majority compositions in 77 community areas of Chicago, Illinois.

Estimating the prevalence of harassment, verbal abuse, and discrimination among residents is difficult as events are often under-reported. The purpose of this study was to determine the prevalence of discrimination and abuse among surgical residents using the HITS (Hurt, Insulted, Threatened with harm or Screamed at) screening tool. A multicenter, cross-sectional, survey-based study was conducted at five academic teaching hospitals. Of 310 residents, 76 (24.5%) completed the survey. The HITS screening tool was positive in 3.9 per cent. The most common forms of abuse included sexual harassment (28.9%), discrimination based on gender (15.7%), and discrimination based on ethnicity (7.9%). There was a positive correlation between individuals who reported gender discrimination and racial discrimination (r = 0.778, n = 13, P = 0.002). Individuals who experienced insults were more likely to experience physical threats (r = 0.437, n = 79, P < 0.001) or verbal abuse (r = 0.690, n = 79, P < 0.001). Discrimination and harassment among surgical residents in academic teaching hospitals across the United States is not uncommon. Further research is needed to determine the impact of these findings on resident attrition.

Background: The adaptation of conferences to virtual platforms has allowed more international colleagues and underrepresented members of the surgical workforce to access educational opportunities. With the purpose of addressing the gap in open-access gender equity education, the Gender Equity Initiative in Global Surgery (GEIGS) held its first general assembly in 2020 as a pathway to promote capacity building on this topic.Objectives: This article aims to report the organization and outcomes of the GEIGS general assembly as an example of opportunities to develop capacity on gender equity and diversity in global surgery using virtual platforms. Project Design and Implementation: The GEIGS General Assembly was a two-day event held on December 12th and December 20th, 2020. The project was led by an organizing committee, composed of 11 individuals of diverse backgrounds, who were divided into logistics, advocacy, and sessions teams. The assembly planning was facilitated through weekly meetings under the supervision of the GEIGS steering committee.Main Achievements: GEIGS piloted a virtual global-scale general assembly that encompassed small-group and international community building, interactive learning, and advocacy. In terms of regional representation, there were 199 attendees from 46 different countries. The event highlighted the need to promote inclusion of non-English speakers in the global surgery community, and sessions about intersectionality; equity, social justice, and diversity; and national surgical, obstetric, and anesthesia planning garnered the most participant engagement. Moreover, social media engagement mirrored an increased utilization of online platforms for educational, advocacy and promotional purposes, enhancing both scholarly dissemination and capacity building. Policy Implications: Engaging in global surgery demands identifying leaders who will build awareness, workforce diversity, and capacity. Our report demonstrates that the topic of gender equity has not held a prominent place in global surgery, and that this first intersectional conference was an initial step to align both agendas and debate the role of female and non-binary health workers in surgical, anesthesia and obstetric specialties in an international, socially engaging, and region-specific context.

This chapter provides an overview of the topic of structural violence as it relates to gun violence. It posits potential evidence-based, social justice-focused solutions practicable for now and generations to come.

OBJECTIVES AND BACKGROUND The aim of this study was to characterize equity and inclusion in acute care surgery (ACS) with a survey to examine the demographics of ACS surgeons, the exclusionary or biased behaviors they witnessed and experienced, and where those behaviors happen. A major initiative of the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force of the Eastern Association for the Surgery of Trauma was to characterize equity and inclusion in ACS. To do so, a survey was created with the above objectives. METHODS A cross-sectional, mixed-methods anonymous online survey was sent to all EAST members. Closed-ended questions are reported as percentages with a cutoff of α = 0.05 for significance. Quantitative results were analyzed focusing on mistreatment and bias. RESULTS Most respondents identified as white, non-Hispanic and male. In the past 12 months, 57.5% of females witnessed or experienced sexual harassment, whereas 48.6% of surgeons of color witnessed or experienced racial/ethnic discrimination. Sexual harassment, racial/ethnic prejudice, or discrimination based on sexual orientation/sex identity was more frequent in the workplace than at academic conferences or in ACS. Females were more likely than males to report unfair treatment due to age, appearance or sex in the workplace and ACS (P ≤ 0.002). Surgeons of color were more likely than white, non-Hispanics to report unfair treatment in the workplace and ACS due to race/ethnicity (P < 0.001). CONCLUSIONS This is the first survey of ACS surgeons on equity and inclusion. Perceptions of bias are prevalent. Minorities reported more inequity than their white male counterparts. Behavior in the workplace was worse than at academic conferences or ACS. Ensuring equity and inclusion may help ACS attract and retain the best and brightest without fear of unfair treatment.

Clinical trials emerged in rapid succession as the COVID-19 pandemic created an unprecedented need for life-saving therapies. Fair and equitable subject selection in clinical trials offering investigational therapies ought to be an urgent moral concern. Subject selection determines the distribution of risks and benefits, and impacts the applicability of the study results for the larger population. While Research Ethics Committees monitor fair subject selection within each trial, no standard oversight exists for subject selection across multiple trials for the same disease. Drawing on the experience of multiple clinical trials at a single academic medical centre in the USA, we posit that concurrent COVID-19 trials are liable to unfair and inequitable subject selection on account of scientific uncertainty, lack of transparency, scarcity and, lastly, structural barriers to equity compounded by implicit bias. To address the critical gap in the current literature and international regulation, we propose new ethical guidelines for research design and conduct that bolsters fair and equitable subject selection. Although the proposed guidelines are tailored to the research design and protocol of concurrent trials in the COVID-19 pandemic, they may have broader relevance to single COVID-19 trials.

BACKGROUND The United States has the highest per-capita incarceration rate and the largest prison population in the world. More than two thirds of recently incarcerated individuals will be arrested again within 3 years of release and may commit crimes as serious as homicide soon after discharge. The pattern of homicidal violence currently remains unknown for recently incarcerated homicide suspects (RIHS) and their victims. METHODS A retrospective analysis of the 36 states included in the 2003 to 2017 National Violent Death Reporting System was performed with a focus on RIHS and their victims. Pearson χ2 and Wilcoxon rank sum tests were used for comparison. RESULTS There were 249 RIHS in the database of the 14,561 homicides where suspect recent incarceration status was documented. Compared with not-recently incarcerated suspects, RIHS were more likely to be White (41% vs. 29%, p < 0.001) and male (97% vs. 91%, p < 0.001). Recently incarcerated homicide suspects more often had a known relationship with the victim (75% vs. 51%, p < 0.001), and these homicides more often occurred in the victim's own home (43% vs. 34%, p = 0.006). Intimate partner violence was a factor in 31% of the RIHS cases (vs. 17%, p < 0.001). The homicide weapon was most likely to be a firearm (57.8%, p < 0.001). Only 6.4% of homicides were due to mental health illness. Gang violence, while more common in the RIHS group, was still only a precipitating factor in 12.0% of the homicides (vs. 7.4%, p = 0.006). CONCLUSION Recently incarcerated homicide suspects are more likely to kill a known person in their own home with a firearm, and these homicides are frequently categorized as intimate partner homicides. Gang violence and mental health are not frequent precipitating factors in these deaths. Additional future interventions are urgently needed to eliminate these preventable deaths by alerting previous or current intimate partners of those being discharged from the prison system.

OBJECTIVE: This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome. METHODS: We retrospectively reviewed patients with PBI admitted to our institution over a two-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome. RESULTS: Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model Intraventricular hemorrhage at presentation was associated with AI (OR=9.9, p=0.004). The same was not true for VSI. CONCLUSION: Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.

In the United States, one in four women and one in seven men experience severe physical IPV at some point in their lives 2 Transgender individuals report even higher levels, with some studies quoting lifetime prevalence of IPV of up to 50% 3 Restricted economic resources, unemployment, and high stress levels all correlate with an increase in both the incidence and the severity of IPV According to the Director for Shelter Services at the Domestic Violence and Child Advocacy Shelter of Cleveland, Ohio, for example, 40% ofcalls in February 2020 were classified as acute crises Many public health experts and epidemiologists believe that several rounds ofshelter-in-place orders may be necessary until a vaccine can be reliably deployed or viral spread has subsided completely

The definition of sepsis continues to be as dynamic as the management strategies used to treat this. Sepsis-3 has replaced the earlier systemic inflammatory response syndrome (SIRS)-based diagnoses with the rapid Sequential Organ Failure Assessment (SOFA) score assisting in predicting overall prognosis with regards to mortality. Surgeons have an important role in ensuring adequate source control while recognizing the threat of carbapenem-resistance in gram-negative organisms. Rapid diagnostic tests are being used increasingly for the early identification of multi-drug-resistant organisms (MDROs), with a key emphasis on the multidisciplinary alert of results. Novel, higher generation antibiotic agents have been developed for resistance in ESKCAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) organisms while surgeons have an important role in the prevention of spread. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial has challenged the previous paradigm of length of antibiotic treatment whereas biomarkers such as procalcitonin are playing a prominent role in individualizing therapy. Several novel therapies for refractory septic shock, while still investigational, are gaining prominence rapidly (such as vitamin C) whereas others await further clinical trials. Management strategies presented as care bundles continue to be updated by the Surviving Sepsis Campaign, yet still remain controversial in its global adoption. We have broadened our temporal and epidemiologic perspective of sepsis by understanding it both as an acute, time-sensitive, life-threatening illness to a chronic condition that increases the risk of mortality up to five years post-discharge. Artificial intelligence, machine learning, and bedside scoring systems can assist the clinician in predicting post-operative sepsis. The public health role of the surgeon is key. This includes collaboration and multi-disciplinary antibiotic stewardship at a hospital level. It also requires controlling pharmaceutical sales and the unregulated dispensing of antibiotic agents globally through policy initiatives to control emerging resistance through prevention.

Trauma patients are at increased risk for venous thromboembolism (VTE). One in four trauma readmissions occur at a different hospital. There are no national studies measuring readmissions to different hospitals with VTE after trauma. Thus, the true national burden in trauma patients readmitted with VTE is unknown and can provide a benchmark to improve quality of care.The Nationwide Readmission Database (2010-2014) was queried for patients ≥18 years non-electively admitted for trauma. Patients with VTE or inferior vena cava filter placement on index admission were excluded. Outcomes included 30-day and 1-year readmission to both index and different hospitals with a new diagnosis of VTE. Multivariable logistic regression identified risk factors. Results were weighted for national estimates.Of the 5,151,617 patients admitted for trauma, 1.2% (n = 61,800) were readmitted within 1 year with VTE. Of those, 29.6% (n = 18,296) were readmitted to a different hospital. Risk factors for readmission to a different hospital included index admission to a for-profit hospital (OR 1.33 [1.27-1.40], p0.001), skull fracture (OR 1.20 [1.08-1.35], p0.001), Medicaid (OR 1.16 [1.06-1.26], p0.001), hospitalization7 days (OR 1.12 [1.07-1.18], p0.001), and the lowest quartile of median household income for patient ZIP code (OR 1.13 [1.07-1.19], p0.01). The yearly cost of 1-year readmission for VTE was $256.9 million, with $90.4 million (35.2%) as a result of different hospital readmission.Previously unreported, over one in three patients readmitted with VTE a year after hospitalization for trauma, accounting for over a third of the cost, present to another hospital and are not captured by current metrics. Risk factors are unique. This has significant implications for benchmarking, outcomes, prevention, and policy.Epidemiological study, level II.

A significant proportion of postoperative readmission occurs at a different hospital and is therefore missed by current benchmarking. There are no national studies tracking readmission at different hospitals after colorectal surgery. This study aimed to determine the national burden of postoperative colorectal readmission, including readmission to a different hospital.The 2013 to 2014 Nationwide Readmissions Database was queried for adults undergoing colorectal surgery. The outcome of interest was 30-day unplanned readmission. Risk factors were identified.There were 79,098 patients admitted during the study period, with 7.1% (n = 5,591) readmitted and of those, 10.2% (n = 569) readmitted to a different hospital. Risk factors for readmission to a different hospital included admission to a high-volume hospital (odds ratio [OR] 1.49 [95% CI 1.17 to 1.91], p0.01), teaching hospital (OR 1.26 [95% CI 1.01 to 1.59], p = 0.04), nonmetropolitan hospital (OR 2.75 [95% CI 1.95 to 3.89], p0.01), hospitalization more than 7 days (OR 1.67 [95% CI 1.33 to 2.10], p0.01), and elective admission (OR 1.57 [95% CI 1.22 to 2.02], p 0.01). Predictors of readmission to a different hospital were different than predictors of readmission. The most common reason for readmission was infection (28.4%).The burden of readmission to a different hospital after colorectal surgery is significant and disproportionately affects high-volume hospitals. Current quality metrics underestimate readmission, failing to capture the subpopulation readmitted to a different hospital. Interventions designed to prevent readmission need to be tailored to the unique risk factors described for different hospital readmission. Benchmarking not measuring different hospital readmission is inaccurate and should be modified.

Background Personal watercrafts (PWC) account for a disproportionate amount of water based injuries. Current literature suggests those with less PWC experience are more at risk for injury. Previous studies have not specifically evaluated the orthopedic implications of PWC usage or how various mechanisms of injury (MOI) contribute to different injury patterns. Hypothesis PWC injuries will frequently require orthopedic intervention. The presence of an orthopedic injury will result in increased injury severity score (ISS), hospital and intensive care unit (ICU) length of stay (LOS). Patients visiting our region will have less PWC experience and so are more prone to serious injuries. Materials and methods Retrospective cohort study at a single Level 1 trauma center of admitted patients sustaining PWC injuries from 02/2004–03/2017. The following were studied: demographics, mechanism, season, ISS, hospital and ICU LOS, follow-up, fracture characteristics and management. Results Hundred and twenty-seven patients were admitted due to PWC injury, 66 (52.0%) sustained an orthopedic injury, totaling 103 fractures (48 [46.6%] lower extremity, 26 [25.2%] upper extremity, 14 [13.6%] vertebral, 11 [10.7%] pelvic ring and 4 [3.9%] acetabulum). The mean age of orthopedic patients was 29 years (range 8–62). Handle bar injuries were significantly associated with open fractures, (13 of 25 open fractures, 3 of which became infected). Injuries occurring during the winter were associated with a higher ISS, yet more injuries occurred in the summer. A patient being a “visitor” to the region did not influence ISS. The mean LOS was 12.6 days for orthopedic patients. Eighteen orthopedic patients (27.3%) required ICU admission and 36 (54.5%) patients required orthopedic surgery (mean 2.11 operations). Discussion A majority of PWC injuries resulted in extremity fractures with a moderate percentage requiring orthopedic surgery. Correlations between PWC experience and injury incidence can provide information for increased safety. Level of evidence IV; retrospective.

Background Mentorship programs in surgery are used to overcome barriers to clinical and academic productivity, research success, and work-life balance. We sought to determine if the Eastern Association for the Surgery of Trauma (EAST) Mentoring Program has met its goals of fostering academic and personal growth in young acute care surgeons. Methods We conducted a systematic program evaluation of EAST Mentoring Program's first 4 years. Demographic information was collected from EAST records, mentorship program applications, and mentee-mentor career development plans. We reviewed the career development plans for thematic commonalities and results of a structured, online questionnaire distributed since program inception. A mixed methods approach was used to better understand the program goals from both mentee and mentor perspectives, as well as attitudes and barriers regarding the perceived success of this career development program. Results During 2012 to 2015, 65 mentoring dyads were paired and 60 completed the program. Of 184 surveys distributed, 108 were returned (57% response rate). Respondents were evenly distributed between mentees and mentors (53 vs. 55, p = 0.768). In participant surveys, mentoring relationships were viewed to focus on research (45%), "sticky situations" (e.g., communication, work-life balance) (27%), education (18%), or administrative issues (10%). Mentees were more focused on research and education versus mentors (74% vs. 50%; p = 0.040). Mentees felt that goals were "always" or "usually" met versus mentors (89% vs. 77%; p = 0.096). Two barriers to successful mentorship included time and communication, with most pairs communicating by email. Most respondents (91%) planned to continue the relationship beyond the EAST Mentoring Program and recommended the experience to colleagues. Conclusion Mentee satisfaction with the EAST Mentoring Program was high. Mentoring is a beneficial tool to promote success among EAST's young members, but differences exist between mentee and mentor perceptions. Revising communication expectations and time commitment to improve career development may help our young acute care surgeons.

In 2017, Cuba was pummeled by Hurricane Irma, one of the strongest and most devastating Atlantic basin hurricanes in history. Twelve of Cuba’s 15 provinces and 90 percent of the population were affected, and there was island-wide loss of electrical power. Despite the significant damage, ongoing economic hardships, and the political realities that required Cuba to handle the situation without response support from other nations, Cuba’s recovery was swift and effective. Cuba’s disaster self-sufficiency and timely response to Hurricane Irma was grounded on 5 decades of disaster planning coupled with ongoing evolution of disaster risk reduction and management strategies. While the central command center, with local dispatch response teams, and mandated citizen engagement are features unique to Cuba’s political structure, in this study, we highlight 5 defining attributes of Cuba’s hurricane response that can constructively inform the actions of other island and coastal nations vulnerable to Atlantic tropical cyclones. These attributes are: (1) actively learning and incorporating lessons from past disaster events, (2) integrating healthcare and public health professionals on the frontlines of disaster response, (3) proactively engaging the public in disaster preparedness, (4) incorporating technology into disaster risk reduction, and (5) infusing science into risk planning. In terms of hurricane response, as a geopolitically isolated nation, Cuba has experienced particular urgency when it comes to protecting the population and creating resilient infrastructure that can be rapidly reactivated after the onslaught of storms of ever-increasing intensity. This includes planning for worsening future disaster scenarios based on a clear-eyed appreciation of the realities of climate change.

Intimate partner violence (IPV) is a public health crisis, affecting at least 1:4 women and 1:9 men. A recent multicenter trial on universal screening in trauma patients showed similar rates of positive screens between men and women. Few studies have explored the bidirectional violence in opposite-sex or same-sex relationships. Our goal was to estimate prevalence and risk factors for the most severe manifestation of IPV: intimate partner homicide.This is a 2003-2015 retrospective review of the National Violent Death Reporting System, a Centers for Disease Control and Prevention database of surveillance data. Deaths were coded IPV if the primary relationship between the suspect and victim fell into the categories of current partner or ex-partner. Bivariable and multivariable analysis examined differences between groups for factors and circumstances.A total of 6,131 persons in opposite-sex relationships and 181 in same-sex relationships were murdered as a result of IPV. Women and Black men were disproportionately affected, and alcohol and preceding arguments were a factor in a higher proportion of male victims. Abuse preceded homicide in many women with almost half of male suspects attempting or committing suicide at the time of intimate partner homicide. Women were more likely than men to use a stabbing instrument, although firearms were still the most common means for each group. In 46.5% of homicides of women, the male suspect attempted suicide (p0.001). Bidirectionality was highest in male victims of female perpetrators and in same-sex pairings regardless of sex of the victim.Homicide caused by IPV is a significant public health crisis for both men and women, with women and Black men at particular risk. Firearms are the most commonly used weapon for homicide in both sexes, and mental illness is not a common risk factor. A staggering proportion of these homicides involve suicide of the suspect, suggesting that each potential incident has two victims to target for prevention and intervention. Interventional programs to prevent such bidirectional mortality are urgently needed.Retrospective secondary data analysis, level III.

Violence can be committed against oneself or against another person or group. As trauma surgeons, we are often required to administer urgent surgical interventions on patients who have sustained life-threatening injuries, including from violence. The roots of such violence, nationally and globally, are related to structures of discrimination and alienation, termed “structural violence.” This is embedded in ubiquitous social structures and normalized by stable institutions and regular experience while “normalizing the abnormal.” Surgeons and physicians have a long history of critical analysis of the upstream “causes of the causes” to understand and prevent further harm. Hate can be well adapted to the classic public health model of the spread of “disease,” with hate speech as the vector leading to direct violence. Social medicine views social inequality as the cause of disease, with political action required to protect and improve population health. It acknowledges the need to address and end structural violence, through political solutions. It is our responsibility to create the dignified environments of growth and progress for our patients and to challenge the agents of harm such as hate and discrimination. As Dr. Norman Bethune, the father of social surgery stated, “Charity should be abolished, and replaced by justice.”

Estimating the prevalence of harassment, verbal abuse, and discrimination among residents is difficult as events are often under-reported. The purpose of this study was to determine the prevalence of discrimination and abuse among surgical residents using the HITS (Hurt, Insulted, Threatened with harm or Screamed at) screening tool. A multicenter, cross-sectional, survey-based study was conducted at five academic teaching hospitals. Of 310 residents, 76 (24.5%) completed the survey. The HITS screening tool was positive in 3.9 per cent. The most common forms of abuse included sexual harassment (28.9%), discrimination based on gender (15.7%), and discrimination based on ethnicity (7.9%). There was a positive correlation between individuals who reported gender discrimination and racial discrimination (r = 0.778, n = 13