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Biomedical subjects

David C Chang

Publications and source records attributed to David C Chang.

At least 19 recordsLinked to original sources
PubMed2006

Why should surgeons care about clinical research methodology?

BACKGROUND: A low prevalence of high-level clinical studies in the surgical literature has been reported previously. We reviewed a recent sample of surgical publications to assess the current status of clinical research. STUDY DESIGN: A 3-month sample of journal articles in Archives of Surgery, Surgery, and Annals of Surgery in 2005 was evaluated by two independent reviewers to determine the distribution of articles in established evidence classes. RESULTS: A total of 133 publications were identified in the three journals during the time periods reviewed, including 101 clinical articles and 30 basic science articles. Among the clinical papers, there were 8 class I studies (7.9%), 34 class II studies (33.7%), and more than half were class III studies (59 of 101, or 58.4%). CONCLUSIONS: The low prevalence of high-level evidence to guide surgical management of patients persists in major general surgery journals. We believe that education about proper research methodology is not only important for researchers, but is also important for practicing surgeons, and can have important health policy implications as well.

Bibliometrics↗
PubMed2006

Preoperative and intraoperative determinants of incisional bulge following retroperitoneal aortic repair.

Although the left flank retroperitoneal incision is a useful approach for many patients undergoing major aortic reconstruction for aneurysmal and occlusive disease, it has been associated with weakening of the flank muscles, resulting in bulges varying from slight asymmetry to huge hernias. The purpose of this study was to determine if the incidence of this complication correlated with identifiable preoperative or intraoperative factors. Fifty consecutive patients undergoing aortic reconstruction via the retroperitoneal approach were followed for 1 year postoperatively for evidence of disfiguring bulges. Bulges were scored as follows: normal/mild, <1-inch protrusion; moderate, protrusion 1-2 inches; severe, protrusion >2 inches and/or pain or true herniation. Preoperatively, patients were administered a questionnaire to elicit demographic and comorbidity data. Fifty-six percent of patients developed a bulge at 1 year. In 43% of these, the bulge was deemed mild and in 54% moderate. One patient developed a severe bulge. Among preoperative comorbidities, no statistically significant correlations were found on bivariate analysis. However, likelihood ratios for bulge development of 5.5 for renal disease and 3.1 for cancer were demonstrated. Conversely, peripheral vascular disease had a likelihood ratio of 0.21 for bulge formation and emphysema, 0.28. On logistic analysis, incision >15 cm and body mass index (BMI) >23 mg/kg(2) were found to correlate strongly with bulge formation (p=0.003, odds ratio=9.1, and p=0.018, odds ratio=16.9, respectively). Together, these yielded a pseudo r (2) of 0.32. BMI >23 mg/kg(2 )was found to yield the greatest explanatory power. These same two variables were found to correlate with severity of bulge: p=0.02 for incision>5 cm and p=0.006 for BMI >23. Of note, gender, age, and extension of the incision into the interspace were not significant on logistic analysis. Preoperatively, surgeons should warn obese patients and those requiring large incisions for extensive disease of their increased risk for poor healing. Intraoperatively, surgeons should aim to minimize incision length.

Aged↗
PubMed2006

Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial.

Pancreatic duct stenting remains an attractive strategy to reduce the incidence of pancreatic fistulas following pancreaticoduodenectomy (PD) with encouraging results in both retrospective and prospective studies. We performed a prospective randomized trial to test the hypothesis that internal pancreatic duct stenting reduces the development of pancreatic fistulas following PD. Two hundred thirty-eight patients were randomized to either receive a pancreatic stent (S) or no stent (NS), and stratified according to the texture of the pancreatic remnant (soft/normal versus hard). Four patients were excluded from the study; in three instances due to a pancreatic duct that was too small to cannulate and in the other instance because a total pancreatectomy was performed. Patients who randomized to the S group had a 6-cm-long segment of a plastic pediatric feeding tube used to stent the pancreaticojejunostomy anastomosis. In patients with a soft pancreas, 57 randomized to the S group and 56 randomized to the NS group. In patients with a hard pancreas, 58 randomized to the S group and 63 randomized to the NS group. The S and NS groups for the entire study population, as well as for the subgroup of high-risk patients with soft pancreata, were similar as regard to demographics, past medical history, preoperative symptoms, preoperative procedures, and intraoperative data. The pancreatic fistula rate for the entire study population was 9.4%. The fistula rates in the S and NS subgroups with hard pancreata were similar, at 1.7% and 4.8% (P = 0.4), respectively. The fistula rates in the S and NS subgroups with soft pancreata were also similar, at 21.1% and 10.7% (P = 0.1), respectively. A nonstatistically significant increase in the pancreatic fistula rate in the S group persisted after adjusting for the operating surgeon and technical details of the operation (e.g., anastomotic technique, anastomotic orientation, pancreatic duct size, and number of intra-abdominal drains placed). In patients with soft pancreata, 63% percent of the pancreatic fistulas in stented patients required adjustment to the clinical pathway (including two deaths), compared to 47% of the pancreatic fistulas in patients in the NS group (P = 0.3). Internal pancreatic duct stenting does not decrease the frequency or the severity of postoperative pancreatic fistulas.

Adult↗
PubMed2006

1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience.

Pancreaticoduodenectomy (PD) with the possible addition of neoadjuvant or adjuvant therapy is the standard of care in the United States for adenocarcinoma originating in the pancreatic head, neck, and uncinate process. We reviewed 1423 patients who underwent a PD for a malignancy originating in the pancreas at our institution between 1970 and 2006. We examined 1175 PDs for ductal adenocarcinomas in greater detail. Eighteen different histological types of pancreatic cancer were identified; the most common diagnoses included ductal adenocarcinoma, neuroendocrine carcinoma, and IPMN with invasive cancer. Patients with ductal adenocarcinoma were analyzed in detail. The median age was 66 years, with patients in the present decade significantly older (68 years), on average, than patients in the three prior decades (e.g., 60 years in 1970, P = 0.02). The median tumor diameter was 3 cm; 42% of the resections had positive margins and 78% had positive lymph nodes. The perioperative morbidity was 38%. The median postoperative stay declined over time, from 16 days in the 1980s to 8 days in the 2000s (P < 0.001). The perioperative mortality declined from 30% in the 1970s to 1% in the 2000s (P < 0.001). The median survival for all patients with ductal adenocarcinoma was 18 months (1-year survival = 65 %, 2-year survival = 37%, 5-year survival = 18%). In a Cox proportional hazards model, pathological factors having a significant impact on survival included tumor diameter, resection margin status, lymph node status, and histologic grade. This is the largest single-institution experience with PD for pancreatic cancer. Patients who have cancers with favorable pathological features have a statistically significant improved long-term survival.

Adult↗
PubMed2006

Trends in the in-hospital stroke rate following carotid endarterectomy in California and Maryland.

OBJECTIVE: We examined the outcome of carotid endarterectomy (CEA) in the state of Maryland during the last decade to identify any trends in the incidence of in-hospital stroke and mortality and compared these results with the outcome of the operation throughout the state of California as a control population. METHOD: We performed a retrospective analysis of 10 years (1994 to 2003) of the Maryland and 5 years (1999 to 2003) of the California hospital discharge databases. The following patients were included in the analysis: (1) International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code 38.12 (endarterectomy of the vessels of the head and neck other than intracranial vessels) in the primary coding position but not in any secondary position, or (2) the diagnosis code 433.00 to 433.91 (occlusion/stenosis, precerebral artery), or (3) the diagnosis-related group (DRG) 5 (extracranial vascular procedure). Symptomatic patients were identified by history of previous stroke (ICD-9 codes 342 or 438), transient ischemic attack (435 or 781.4), or amaurosis fugax (362.34 or 368.12). In-hospital strokes were identified by ICD-9 codes 997.0, 997.00, 997.01, and 997.09. Low-, moderate-, and high-volume surgeons were defined as performing <15, 15 to 74 and >or=75 CEAs annually. Hospital volumes were similarly classified as low for those performing 100 annually. RESULTS: In the Maryland data, 23,237 CEA cases were identified with 169 in-hospital strokes over 10 years (0.73%), whereas the 51,331 California CEAs had 232 in-hospital strokes over 5 years (0.45%). The stroke rate in Maryland was 2.12% in 1994, 1.47% in 1995, and 0.29% to 0.65% from 1996 to 2003. The decrease in strokes was more pronounced among symptomatic patients, where the rate was 3.82% in 1994, 4.44% in 1995, and 0.90% to 2.29% from 1996 to 2003. A similar decrease was identified in the asymptomatic patient population but was less pronounced: 1.64% in 1994, 0.81% in 1995, and 0.15% to 0.44% from 1996 to 2003. The low recent stroke rates were confirmed by the California data (0.44% to 0.48% from 1999 to 2003). Changes in the death rate for CEA during this time frame have not been as pronounced, from 0.33% to 0.58% for Maryland and 0.78% to 0.91% for California. CONCLUSIONS: A dramatic decrease in the in-hospital stroke rates in Maryland occurred around 1995. The stroke rates in Maryland in the past 5 years are similar to those in California during the same period. An analysis of data from the two states shows that the in-hospital stroke rate now for carotid endarterectomy is approximately 0.54%.

Adult↗
PubMed2006

The Southern Surgical Association History of Medicine Scholarship presentation: Dr. Charles Drew, a surgical pioneer.

When one considers the circumstances of his birth, the barriers that he had to overcome, and his abbreviated life span (<46 years), a strong case can be made that Charles Drew, MD, CM, MDSc, was one of the most accomplished surgeons of the 20th Century; yet many practitioners and instructors of the surgical sciences know little or nothing about him. There are others who have heard of him and still harbor popular misconceptions about the circumstances of his death that have been perpetuated by several media outlets. The Southern Surgical Association promotes a substantially more inclusive brand of surgical fellowship than it did during the lifetime of Dr. Drew. We believe that the membership would greatly appreciate knowing some of the details of Dr. Drew's life, particularly his major scientific contributions and his commitment to excellence in patient care, and in the training of young surgeons.

District of Columbia↗
PubMed2006

Injured patients have lower mortality when treated by "full-time" trauma surgeons vs. surgeons who cover trauma "part-time".

BACKGROUND: Studies examining the effect of trauma surgeon volume on patient outcomes have had disparate results. We hypothesize that "full-time" trauma surgeons would have lower patient mortality rates than surgeons covering trauma "part-time." METHODS: Retrospective review of 14,171 patients during a span of 6.5 years (January 1998 to June 2004) from the trauma registry at an urban, university-based Level I trauma center. "Full-time" surgeons practiced primarily trauma, emergency surgery, and critical care. "Part-time" surgeons took trauma call, but mainly practiced another type of surgery (e.g., pancreatic, hepatobiliary, vascular, transplant). Chi square and multiple logistic regression compared mortality between groups. RESULTS: There were no differences in patient demographics or admission injury patterns between the two groups. On bivariate analysis, the subgroup of patients with severe head injury had lower mortality when treated by "full-time" surgeons. With ED deaths excluded, more severely injured patients (Injury Severity Score [ISS] >15) had a survival benefit in the "full-time" group. Multiple logistic regression showed a 50% increase in mortality for patients treated by "part-time" trauma surgeons when adjusting for age, sex, ISS >15, severe head injury, hypotension, nighttime admission, day of the week, and penetrating mechanism (odds ratio of death 1.45, 95% CI 1.04-2.02). Similar results are seen in only patients surviving to emergency room discharge (odds ratio of death 1.50, 95% CI 1.01-2.22). Z and W scores showed higher than expected survival for all patients with the "full-time" cohort showing a larger benefit. CONCLUSIONS: Even within an established trauma program treating many injured patients, mortality is significantly lower in patients initially treated by "full-time" trauma surgeons.

Adult↗
PubMed2006

Patterns and outcomes among penetrating trauma recidivists: it only gets worse.

BACKGROUND: Trauma recidivism accounts for a significant proportion of visits to urban trauma centers. The current study was designed to characterize injury patterns among individual recidivists and analyze their impact on mortality. METHODS: Recidivists were identified within a trauma registry from an urban level-one trauma center from a period between 1997 and 2004. Demographic, injury type, and final disposition data were retrospectively reviewed. The primary outcomes measured were all-cause mortality and injury mechanism. The data were analyzed using the chi2 method, and logistic regression analysis. RESULTS: Among 15,973 total trauma visits, 2,511 (15.7%) were by recidivists, representing 1,528 unique patients. Of these recidivists, 794 (52%) had their first trauma admission during the period reviewed (84% male, 87% African-American, mean age 31 +/- 13 years). Blunt injuries only were identified in 43.8% patients, while 21.9% had penetrating injuries only, and 34.3% had a combination of injury patterns. Recidivists presenting with penetrating trauma as their initial injury were more likely to return with penetrating injuries on their second (58% vs. 25% [p < 0.001]) and third (68% vs. 24% [p < 0.001]) visits. The all-cause mortality of a penetrating injury was significantly higher than that of a blunt injury for both second (9.2% vs. 1.0% [p < 0.001]) and third (15.1% vs. 1.3% [p = 0.002]) visits. The likelihood of mortality increased over twofold for each subsequent penetrating trauma visit (odds ratio [OR]; 95% confidence interval [CI]; 2.20 [1.63-2.97], p < 0.001). CONCLUSIONS: Individual recidivists with penetrating injuries are likely to return with the same injury pattern, and are at increased risk of death with each subsequent visit.

Adult↗
PubMed2006

Multiple, simultaneous trauma patients: Are they worse off?

BACKGROUND: The simultaneous management of multiple severely injured patients has the potential to overwhelm trauma center resources. We hypothesize that trauma patients presenting in clusters of two or more patients within a short time period have worse outcomes. METHODS: From the registry at our urban Level I trauma center, we reviewed 4,619 "major" trauma patients admitted during a span of 5.5 years (January 1998 through June 2003). A multidisciplinary team led by an in-house trauma surgery attending evaluated all patients. Pairs of two patients presenting less than 10 minutes apart (PAIRS) and clusters of three patients presenting within 30 minutes (CLUSTERS) were compared with patients arriving alone presenting over 4 hours apart (ALONE) and to other patients that did not meet any of the above criteria (OTHER). Multivariate regression was performed to determine differences in likelihood of direct operating room admissions, hospital, and intensive care unit (ICU) length of stay, and mortality. RESULTS: PAIRS made up 8.9% (413) and CLUSTERS made up 2.7% (126) of patients; 42% (1,939) arrived ALONE; 48.3% (2,229) of patients were classified as OTHER. Multivariate regression showed no significant differences in ICU or hospital length of stay, or mortality for PAIRS or CLUSTERS compared with patients presenting ALONE. PAIR and CLUSTER patients were more likely to undergo immediate surgery than the ALONE group (odds ratio 1.37, 95% confidence interval 1.03-1.83 and 1.61, 95% CI 1.00-2.58, respectively). CONCLUSIONS: When PAIRS or CLUSTERS of seriously injured patients arrive in close time proximity, they are more likely to be directly admitted to the operating room than patients arriving ALONE. This difference in management does not appear to affect patient outcomes.

Adult↗
PubMed2005

Surgical ventricular remodeling for multiterritory myocardial infarction: defining a new patient population.

OBJECTIVE: Because of limited medical and surgical options for patients with end-stage congestive heart failure, we expanded the criteria for surgical ventricular remodeling to include patients with multiterritory myocardial infarction, a group historically considered high-risk candidates. We present our series of patients with multiterritory myocardial infarction who underwent surgical ventricular remodeling and propose a new patient population who may benefit from this procedure. METHODS: Data were analyzed for 51 consecutive patients undergoing surgical ventricular remodeling from January 2002 to June 2004, with 100% follow-up. Three left ventricular vascular territories were defined: anteroapicoseptal (left anterior descending), lateral (circumflex), and inferior (right coronary artery). Infarction was assessed with magnetic resonance imaging and intraoperative findings. RESULTS: Multiterritory myocardial infarction was found in 64.7% of patients (33/51) undergoing surgical ventricular remodeling. Mean age was 61.6 +/- 11.1 years (range 40-81 years). Sixty-one percent (20/33) demonstrated evidence of myocardial infarction in all three territories. Five patients underwent concomitant mitral valve repair or replacement. Operative mortality was 6.1% (2/33) and did not differ from that of patients with single-territory infarction (11.1%, P = .61). Surgical ventricular remodeling significantly improved left ventricular volumes and ejection fraction in patients with multiterritory myocardial infarction. Three patients required assist device implantation, and 2 patients required defibrillator placement. Sixty-nine percent of patients in preoperative New York Heart Association functional class III or IV (22/32) had improvement to class I or II at follow-up (P < .01). Cox regression analysis discriminated a preoperative left ventricular end-systolic volume index greater than 100 mL/m(2) as a significant risk factor for mortality (odds ratio 12.1, 95% confidence interval 1.27-114.51, P = .03). Thirty-month survival of patients with multiterritory myocardial infarction (73.5% +/- 8.3%) did not differ statistically from that of patients with single-territory infarction (n = 18). CONCLUSION: Surgical ventricular remodeling improves cardiac function and New York Heart Association functional status in patients with multiterritory myocardial infarction. Our initial results are promising and should prompt further studies to confirm our results and potentially expand the surgical ventricular remodeling inclusion criteria to include patients with multiterritory myocardial infarction.

Adult↗
PubMed2005

A multidisciplinary youth violence-prevention initiative: impact on attitudes.

BACKGROUND: In a previous report, enhanced resource commitment at a Level I trauma center was associated with improved outcomes for most major categories of injured patients, except those with gunshot wounds, which disproportionately affected the young (ages 15 to 24 years). We hypothesized that a primary violence-prevention initiative geared toward changing attitudes about interpersonal conflict among at-risk youths can be effective. STUDY DESIGN: Between May 2002 and November 2003, 97 youths (mean age 12.6 years) were recruited from one of two Police Athletic League centers in the catchment area of our Level I trauma center. Participant attitudes about interpersonal conflicts were surveyed with six previously validated scales before and after a hospital tour with a video and slide presentation graphically depicting the results of gun violence. Mean differences in scores between pre- and postintervention surveys were assessed. RESULTS: Of the 97 participants, 48 (49.4%) completed the intervention program with both the pre- and postintervention tests, with a mean of 25.8 days between tests. There was a statistically significant reduction in the Beliefs Supporting Aggression scale (mean -0.38 U; 95% CI, -0.23 to -0.54; p < 0.01), and a trend toward reduced Likelihood of Violence (mean -0.17 U; 95% CI, 0.01 to -0.34; p = 0.06). CONCLUSIONS: A multidisciplinary violence-prevention outreach program can produce short-term improvement in beliefs supporting aggression among at-risk youth. Longterm impact of this attitude change needs to be examined in future studies.

Aggression↗
PubMed2005

The multi-institutional validation of the new screening index for physical child abuse.

BACKGROUND/PURPOSE: There is currently no evidence-based screening instrument to assist in the detection of physical child abuse patients. The screening index for physical child abuse (SIPCA) was previously developed as a potentially new tool for this need. It is a scale that assigns point values, on the basis of variable weights from logistic regression models, to age and patterns of injuries (including fracture of base or vault of skull, contusion of eye, rib fracture, intracranial bleeding, multiple burns), with higher scores indicating greater suspicion for abuse. The purpose of this study is to validate this new tool in another independent data set. METHODS: A cross-sectional hospital discharge database from 1961 hospitals in 17 states is used (n = 58558). Children aged 14 years or younger with International Classification of Diseases, Ninth Revision, Clinical Modification codes 800 to 959 are included for analysis. Child abuse cases are identified by E codes and certain International Classification of Diseases, Ninth Revision, Clinical Modification codes in the 995.5x range. Screening index for physical child abuse performance is evaluated by discrimination (receiver operating characteristic) and goodness of fit (pseudo r2). RESULTS: A total of 447 abused patients (0.76%) was identified. The receiver operating characteristic of SIPCA in this data set is 0.89 as compared with 0.86 in the development data set. The pseudo r 2 of SIPCA in this data set is 0.26 as compared with 0.28 in the development data set. A SIPCA score of 3 has a sensitivity of 86.6% and a specificity of 80.5% for detecting physical abuse; raising the threshold to a score of 4 improves the specificity to 93.1% but at a loss of sensitivity to 71.8%. CONCLUSIONS: The validity of the new SIPCA instrument is supported by its performance in an independently derived data set. A score of 3 on SIPCA represents a balanced trade off in the sensitivity and specificity of the instrument in detecting physical abuse and is an optimal threshold above which to begin considering abuse in differential diagnosis. Application of the instrument could assist clinicians in detecting physical child abuse cases among pediatric trauma patients.

Age Factors↗
PubMed2005

A preliminary clinical scale to predict the risk of in-hospital death after carotid endarterectomy.

OBJECTIVE: Carotid endarterectomy (CEA) remains the gold standard for the treatment of carotid disease, with mortality rates generally at 0.4% to 1.7%. Controversy remains with regards to its role in the treatment of the high-risk surgical population. We developed a new clinical scale incorporating weighted risk factors into a single numerical score that correlates with the risk of in-hospital death after CEA. We propose that this tool may serve to prospectively identify the high-risk patient. METHODS: We performed a retrospective analysis of 10 years (1994 to 2003) of the Maryland hospital discharge database. Included in the analysis were patients with (1) International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code 38.12 (endarterectomy of the vessels of the head and neck other than intracranial vessels) in the primary coding position but not in any secondary position, or (2) Diagnosis Code 433.00 to 433.91 (occlusion/stenosis, precerebral artery), or (3) the Diagnosis-Related Group 5 (extracranial vascular procedure). ICD codes representing preoperative conditions of the patients were identified and evaluated with stepwise regression modeling techniques for association with in-hospital deaths. Different regression models were evaluated and compared by discriminative power as measured by receiver operating characteristics (ROC) and goodness-of-fit to data as measured by r(2) and the Hosmer-Lemeshow statistic. A numeric index correlating with the risk of in-hospital death was constructed by rounding the correlation coefficients for the statistically significant variables from the logistic regression. RESULTS: We identified 23,237 cases. The mean age of patients was 70.6 years, with 54.7% male patients. There were 125 in-hospital deaths (0.54%). Patient age and four patient medical conditions emerged with significant associations with in-hospital deaths after CEA, and their relationships can be summarized in a single diagnostic scale: 1 point for age > or =75, 2 points for atherosclerosis (ICD code 440), 3 points for cardiomyopathy (ICD code 425), 4 points for iron-deficiency anemia (ICD code 280), and 5 points for cerebral degeneration (ICD code 331). This scale has moderate discriminative power (ROC = 0.67). On average, each point increase on this scale is associated with a 1.58-times increase in mortality risk, with score of 6 on the scale carrying a mortality risk >5%. CONCLUSIONS: This new 5-item scale, based on patient age and past medical history, correlates moderately with the rate of in-hospital death after CEA. This clinical index may serve to identify high-risk patients. Future improvements to this diagnostic scale should focus on the diagnostic values of additional laboratory and demographic data.

Aged↗
PubMed2005

Racial disparities in emergency surgical care.

Socioeconomic factors and differences in access to health care systems, perhaps more so than physiologic differences, play a significant role in race-based differences faced by acute care practitioners.

Black or African American↗
PubMed2004

The tip of the iceberg for child abuse: the critical roles of the pediatric trauma service and its registry.

BACKGROUND: The incidence of child abuse is approximately 10% of all children presenting to an emergency department (ED), with a mortality rate less than 1%. By contrast, the characteristics of the subset of abused children presenting to a pediatric trauma service (PTS) is not well defined. METHODS: This study was a retrospective evaluation of prospectively collected information from an urban Level I pediatric trauma registry from 1990 to 2002 (n = 11,919). Child abuse cases and their perpetrators were identified by E-codes. Patterns of injuries were examined by integer International Classification of Diseases, Ninth Revision codes, and diagnostic model was evaluated by discrimination and goodness-of-fit. RESULTS: A total of 171 cases of child abuse (1.4%) were identified, and the majority were boys (59%, p > 0.05 vs. nonabuse cases). The median age of the abused cohort was younger than 1 year old, and the number of abuse cases did not differ over time (mean, 11 per year.) Abused children present with a higher median Injury Severity Score (10 vs. 4, p < 0.01), more severe injuries of the head and integument, longer hospital lengths of stay (4 vs. 1 day, p < 0.01), and a higher mortality rate (12% vs. 2%, p < 0.01). The following variables emerged with significant association to abuse: fracture of base or vault of skull, contusion of eye, rib fracture, intracranial bleeding, multiple burns, and age. A new Diagnostic Index for Physical Child Abuse was created. CONCLUSION: Significant characteristics of the abused children in this pediatric trauma service include higher Injury Severity Score (especially in the head and integument), requirement for longer lengths of stay, and a nearly 10-times higher risk of death compared with the ED population. The Diagnostic Index for Physical Child Abuse is proposed as a new tool to assist in the identification of child abuse among pediatric trauma patients. An epidemiologic triangle for child abuse is described, with different prevalence and severity of child abuse seen at different levels of our health care system, starting with primary care providers, followed by the ED, the PTS, and ultimately the medical examiners. The number of cases decreases from the bottom to the top of the health care system, but the mortality rate increases as abuse escalates through the triangle. This establishes the PTS as possibly the final gatekeeper before an abused case becomes a fatality. These data emphasize the need for rigorous registry evaluation and subsequent evidence-based prevention initiatives.

Baltimore↗
PubMed2003

Enhanced trauma program commitment at a level I trauma center: effect on the process and outcome of care.

HYPOTHESIS: With advances in surgical care, the occurrences of major adverse outcomes have become a rare event. The effect of a surgical service can be more comprehensively evaluated by following the Donabedian model, looking at the triad of structure, process, and outcome. It is hypothesized that the implementation of a focused program commitment at a trauma center is associated with improvements in process of care and patient outcomes. DESIGN: Evaluation of prospectively collected information in a trauma registry for the 3-year periods immediately before (1995-1997) and after (1999-2001) the implementation (in 1998) of the full-time trauma service. SETTING: Level I university-affiliated trauma center. PATIENTS: Patients meeting criteria for major trauma. INTERVENTION: The implementation of a full-time trauma service, featuring 24-hour in-house attending coverage, dedicated trauma admitting unit, regular trauma core curriculum, regular multidisciplinary quality assurance meetings, and state designation for level I status. MAIN OUTCOME MEASURES: Process of care measures, including time in the emergency department (ED) and trauma "bypass" hours (ie, time spent in the trauma resuscitation area). Outcome measures, including lengths of stay, overall mortality and mortality, excluding ED deaths. RESULTS: The total number of patients with major trauma increased from 2240 (1995-1997) to 2513 (1999-2001). The average time in the ED for patients going to the operating room, intensive care unit, and observation wards all decreased significantly (84 vs 52 minutes, 197 vs 118 minutes, and 300 vs 140 minutes, respectively; all with P<.01). The number of hours that the trauma center was closed owing to ED overcrowding also decreased significantly, from 56 to 2.7 hours per month (P<.01). After excluding ED deaths, there was a trend on bivariate analyses toward lower overall mortality rates (4.5% vs 3.4%, P =.07) and mortality rates among patients with severe head injury (23.8% vs 17.2%, P =.07). On further analyses with multiple logistic regression, controlling for age, Injury Severity Score, Abbreviated Injury Score (for a head injury), and admission blood pressure, the later period is associated with a 31% decrease in overall odds of death (P =.047) and a 42% decrease in odds of death among patients with severe head injury (an Abbreviated Injury Score, >or=3; P =.03). CONCLUSION: The implementation of a full-time trauma service is associated with improved timeliness of triage and therapeutic interventions and improved patient outcomes.

Adult↗
PubMed2003

Pediatric trauma care: an overview of pediatric trauma systems and their practices in 18 US states.

PURPOSE: The aim of this study was to describe the state of pediatric trauma system development in the United States in 1997 and 1998 and to characterize the hospitalization patterns of injured children in states with different types of pediatric trauma systems. The authors also investigated the impact of sociodemographic, injury, and geographic characteristics on those hospitalization patterns. METHODS: The authors combined statewide hospital discharge data on hospitalized trauma patients less than 15 years old with data from the American Hospital Association, the Area Resource File, the Office of Management and Budget, the states' Departments of Health, and the US Census. Besides conducting descriptive analyses, the authors evaluated the role of several parameters in determining the likelihood of treatment in trauma and nontrauma centers using multivariate multinomial logistic regression models. RESULTS: There were 15 states with adult and pediatric trauma designation systems; 9 of them had statewide hospital discharge data available. In these 9 states, 77% of the discharges were from trauma centers with no pediatric designation. More severely injured children and children with injuries to the head, face, thorax, and abdomen were more likely to be discharged from trauma centers, although large percentages of these children were treated in nontrauma centers. Older children and children with commercial insurance were less likely to be treated at trauma centers, even when injury severity, body region injured, and other factors were accounted for. CONCLUSIONS: Even in states with trauma systems, a large proportion of severely injured children are treated in nontrauma center facilities.

Adolescent↗