Trauma Centers with Higher Rates of Angiography Have a Lesser Incidence of Splenectomy in the Management of Blunt Splenic Injury

The Journal of Emergency Medicine in one Level 1 rural trauma center in North Carolina. Excluded were patients with baseline cognitive deficit, dementia, traumatic brain injury (TBI) associated memory impairment, altered mental status (AMS), delirium, or Glascow coma scale (GCS) less than 15. Past-year IPV, alcohol and substance abuse, and mental illness were screened using a variety of previously validated questionnaires. No such questionnaire existed for lifetime IPV, so one was developed for this study. Additional patient characteristics were obtained, including access to a primary care provider, firearm access, past-year treatment for mental illness or substance abuse, past screening for IPV, and injury characteristics. Eighty-one patients were enrolled in the study; 51% reported lifetime IPV and 31% reported past-year IPV. Patients who reported both lifetime and past-year IPV were more likely to be younger than 50 years of age, were more likely to be in a current relationship, were more likely to report having been previously screened for IPV, were more likely to have a history of mental illness, and were more likely to have a mechanism of assault or self-inflicted injury with a weapon for the index hospitalization. Patients reporting lifetime IPV were more likely to be uninsured, less likely to have primary care provider access, more likely to report suicidal ideation, and more likely to have substance abuse history. Patients reporting past-year IPV were more likely to report having a partner with a firearm, more likely to report alcohol abuse, and more likely to report an intentional mechanism of injury related to the index hospitalization. The authors concluded that the prevalence of IPV within their trauma population was high, and that it was positively associated with mental illness, alcohol and substance abuse, and partner firearm ownership. [Timothy L. Vo, MD Denver Health Medical Center, Denver, CO] Comment: This prospective cross-sectional study sheds light on the characteristics of female trauma patients exposed to IPV. Mental illness, suicidal ideation, alcohol and substance abuse history, and cause for index hospitalization related to intentional mechanism were positively associated with either lifetime or past-year IPV. Notably, no significant differences were found for race, employment status, educational attainment, income, rural residence, or previous traumatic injury. Because this was a single center study in an English-speaking rural population, generalizability to all trauma populations may not be feasible. However, the authors did find a high IPV prevalence and posit that IPV screening and brief intervention, along with the alcohol abuse screening and brief intervention mandated by the American College of Surgeons for Level 1 trauma centers, might positively impact patient outcomes and recidivism rates. , TRAUMA CENTERS WITH HIGHER RATES OF ANGIOGRAPHY HAVE A LESSER INCIDENCE OF SPLENECTOMY IN THE MANAGEMENT OF BLUNT SPLENIC INJURY. Capecci LM, Jeremitsky E, Smith RS, et al. Surgery. 2015;158:1020-1025 Angiography has become a valuable tool in management of blunt splenic injury (BSI) especially as the management

705 paradigm has shifted from operative to nonoperative over the past 30 years. However, use of angiography has not been standardized, with protocols varying widely between institutions. This is especially illustrated when comparing single-center studies with large multi-center studies. This study attempted to determine whether high versus low rate of angiography were associated with decreased rates of splenectomy. The Pennsylvania Trauma Systems Foundation database was used to generate the study cohort. Patients less than 13 years of age or with penetrating trauma were excluded. A frequency of 13% was used to define a high versus low angiography center. Patient demographics, grade of BSI, level of trauma center, and patient volume were analyzed. Between 2007 and 2011, 5333 patients in 28 trauma centers were identified. Angiography rates varied from 2% to 27%, with an overall rate of 21%. High angiography centers had a lower rate of splenectomy than low angiography centers (19% versus 24%, p<.001; odds ratio 0.68, 95% CI 0.58-0.80, p<.001). Between high and low angiography centers, BSI rates, grade of BSI, and overall injury severity did not significantly differ. HIgh angiography centers were more likely to have a Level 1 designation (79% vs 56%, p<.001), while low angiography centers were more likely to be high-volume centers (54% versus 41%, p<.001). The study authors concluded that high institutional angiography rates were associated with lower rates of splenectomy within that institution. [Timothy L. Vo, MD Denver Health Medical Center, Denver, CO] Comment: This retrospective cohort study showed that high angiography centers achieved a lower splenectomy rate. However, 30% of injuries were ungraded, which may have confounded the data. Further, no data is presented regarding potential complications from angiography, including bleeding or hematoma, formation of pseudoaneurysm at puncture site, splenic infection or abscess, or contrast-induced nephropathy. The optimal rate of angiography is yet to be determined; however, this study provides important information about the potential role of angiography in the management of splenic injury. , ASSOCIATION OF MODEL FOR END-STAGE LIVER DISEASE SCORE AND MORTALITY IN TRAUMA PATIENTS WITH CHRONIC LIVER DISEASE. Peetz A, Salim A, Askari R, et al. JAMA Surg. 2016;151:41-48 Cirrhosis and chronic liver disease (CLD) have been shown to have an association with worse outcomes in trauma patients, in what appears to be a dose-response relationship relative to severity of disease. However, thus far, no studies have been performed to assess the effect of dynamic changes in liver disease and functioning on outcomes in the ongoing care of trauma patients. This study was performed to determine whether a change in Model of End-Stage Liver Disease (MELD) score was associated with mortality in critically ill trauma patients. Data from patients admitted to 2 Level 1 trauma centers in Boston were