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Background: End-of-life (EOL) care is associated with high resource utilization. Recognizing and effectively communicating that EOL is near promotes more patient-centered care, while decreasing futile interventions. We hypothesize that provider assessment of futility during the surgical intensive care unit (SICU) admission would result in higher rates of Do Not Resuscitate (DNR). Methods: We performed a retrospective review of a prospective SICU registry of all deceased patients across a health system, 2018-2022. The registry included a subjective provider assessment of patient's expected survival. We employed multivariable logistic regression to adjust for clinical factors while assessing for association between code status at death and provider's survival assessment with attention to race-based differences. Results: 746 patients-105 (14.1%) traumatically injured and 641 (85.9%) non-traumatically injured-died over 4.5 years in the SICU (mortality rate 5.9%). 26.3% of these deaths were expected by the ICU provider. 40.9% of trauma patients were full code at the time of death, compared with 15.6% of non-traumatically injured patients. Expected death was associated with increased odds of DNR code status for non-traumatically injured patients (OR 1.8, 95% CI 1.03 to 3.18), but not for traumatically injured patients (OR 0.82, 95% CI 0.22 to 3.08). After adjusting for demographic and clinical characteristics, black patients were less likely to be DNR at the time of death (OR 0.49, 95% CI 0.32 to 0.75). Conclusion: 20% of patients who died in our SICU had not declared a DNR status, with injured black patients more likely to remain full code at the time of death. Further evaluation of this cohort to optimize recognition and communication of EOL is needed to avoid unnecessary suffering. Level of evidence: Level III/prognostic and epidemiological.

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BACKGROUND: Injured patients have high rates of uninsurance, which is associated with worse outcomes. Insurance linkage programs that connect patients to Medicaid coverage can prevent catastrophic costs for patients. Less is known about the long-term impact of insurance enrollment. We examined health care utilization for previously uninsured patients, hypothesizing that newly insured patients postinjury would use health care more than those remaining uninsured. METHODS: We linked institutional trauma registry data to the electronic medical record to identify injured patients aged 18 to 64 years from 2017 to 2021. Patients admitted without insurance and then retroactively insured (RI) during hospitalization were compared with patients with preestablished Medicaid (Medicaid insured [MI]) and those remaining uninsured. We compared demographic and injury characteristics and future health care utilization, including hospitalizations, emergency department (ED) visits, and clinic visits, among groups at 30 days and 12 months postinjury. Patient-reported outcomes (PROs) 6 months after injury were compared by group for a subset of patients participating in an ongoing study of long-term PROs. RESULTS: We compared 494 RI patients with 1,706 MI and 148 uninsured patients. Retroactively insured patients were younger, more likely to have penetrating injuries, and longer hospitalization than other groups. There was a significant increase in ED and clinic visits and hospital admissions at 30 days and 12 months between RI and uninsured patients (p < 0.001). Using multivariable logistic regression, RI was associated with higher future ED utilization, hospital admissions, and specialist visits at 30 days and 12 months compared with uninsured patients. Of the 265 patients with 6-month PROs, Medicaid coverage was not associated with any significant difference in physical function or anxiety. CONCLUSION: Patients enrolled in insurance postinjury are more likely to use health care in the future than patients without insurance, but the downstream effects are less clear. Health insurance is a necessary step but not independently sufficient to optimize care and improve health outcomes. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

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Background: Although timely access to trauma center (TC) care for injured patients is essential, the proliferation of new TCs does not always improve outcomes. Hospitals may seek TC accreditation for financial reasons, rather than to address community or geographic need. Introducing new TCs risks degrading case and payer mix at established TCs. We hypothesized that newly accredited TCs would see a disproportionate share of commercially insured patients. Study design: We collected data from all accredited adult TCs in Pennsylvania using the state trauma registry from 1999 to 2018. As state policy regarding supplemental reimbursement for underinsured patients changed in 2004, we compared patient characteristics and payer mix between TCs established before and after 2004. We used multivariable logistic regression to assess the relationship between payer and presentation to a new versus established TC in recent years. Results: Over time, there was a 40% increase in the number of TCs from 23 to 38. Of 326 204 patients from 2010 to 2018, a total of 43 621 (13.4%) were treated at 15 new TCs. New TCs treated more blunt trauma and less severely injured patients (p<0.001). In multivariable analysis, patients presenting to new TCs were more likely to have Medicare (OR 2.0, 95% CI 1.9 to 2.1) and commercial insurance (OR 1.6, 95% CI 1.5 to 1.6) compared with Medicaid. Over time, fewer patients at established TCs and more patients at new TCs had private insurance. Conclusions: With the opening of new centers, payer mix changed unfavorably at established TCs. Trauma system development should consider community and regional needs, as well as impact on existing centers to ensure financial sustainability of TCs caring for vulnerable patients. Level of evidence: Level III, prognostic/epidemiological.

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BACKGROUND: Firearm injuries are the leading cause of death in children and adolescents in the USA. We hypothesised that high rates of risky behaviour in high school students are associated with firearm injury and death in this population. METHODS: We obtained data from the Youth Behaviour Risk Survey of the Centers for Disease Control and Prevention (CDC) and combined it with data from the CDC Web-based Injury Statistics Query and Reporting System, CDC Wide-ranging Online Data for Epidemiologic Research and American Community Survey, 2001-2020. We examined trends over time using a non-parametric test for trends. RESULTS: The percentage of high school-aged youth carrying a weapon in the preceding 30 days ranged from 13.2% in 2019 to 18.5% in 2005, without a statistically significant trend over time (p=0.051). Those carrying a weapon to school peaked at 6.5% in 2005 and steadily downtrended to 2.8% in 2019 (p=0.004). Boys consistently reported higher rates of weapon carriage, with white boys reporting higher rates than black boys. Firearm homicides among adolescents 14-18 years showed no significant change, ranging from 4.0 per 100k in 2013 to 8.3 per 100k in 2020. This varied considerably by sex and race, with black boys suffering a rate of nearly 60 per 100 000 in 2020 and white girls rarely exceeding 1/100 000 during the study period. CONCLUSION: Self-reported weapon carriage among teens in the USA has steadily downtrended over time. However, shooting injuries and deaths have not. While the former suggests progress, the latter remains concerning. LEVEL OF EVIDENCE: Level III; retrospective cohort study.

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BACKGROUND: We examined outcomes in Acute Mesenteric Ischemia (AMI) with the hypothesis that Open Abdomen (OA) is associated with decreased mortality. METHODS: We performed a cohort study reviewing NSQIP emergency laparotomy patients, 2016-2020, with a postoperative diagnosis of mesenteric ischemia. OA was defined using flags for patients without fascial closure. Logistic regression was used with outcomes of 30-day mortality and several secondary outcomes. RESULTS: Out of 5514 cases, 4624 (83.9%) underwent resection and 387 (7.0%) underwent revascularization. The OA rate was 32.6%. 10.8% of patients who were closed required reoperation. After adjustment for demographics, transfer status, comorbidities, preoperative variables including creatinine, white blood cell count, and anemia, as well as operative time, OA was associated with OR 1.58 for mortality (95% CI [1.38, 1.81], p < 0.001). Among revascularizations, there was no such association (p = 0.528). OA was associated with ventilator support >48 h (OR 4.04, 95% CI [3.55, 4.62], and p < 0.001). CONCLUSION: OA in AMI was associated with increased mortality and prolonged ventilation. This is not so in revascularization patients, and 1 in 10 patients who underwent primary closure required reoperation. OA should be considered in specific cases of AMI. LEVEL OF EVIDENCE: Retrospective cohort, Level III.

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INTRODUCTION: Organized trauma systems reduce morbidity and mortality after serious injury. Rapid transport to high-level trauma centers is ideal, but not always feasible. Thus, interhospital transfers are an important component of trauma systems. However, transferring a seriously injured patient carries the risk of worsening condition before reaching definitive care. In this study, we evaluated characteristics and outcomes of patients whose hemodynamic status worsened during the transfer process. METHODS: We conducted a retrospective cohort study using data from the Pennsylvania Trauma Outcomes Study database from 2011 to 2018. Patients were included if they had a heart rate ≤ 100 and systolic blood pressure ≥ 100 at presentation to the referring hospital and were transferred within 24 h. We defined hemodynamic deterioration (HDD) as admitting heart rate > 100 or systolic blood pressure < 100 at the receiving center. We compared demographics, mechanism of injury, injury severity, management, and outcomes between patients with and without HDD using descriptive statistics and multivariable regression analysis. RESULTS: Of 52,919 included patients, 5331 (10.1%) had HDD. HDD patients were more often moderately-severely injured (injury severity score 9-15; 40.4% versus 39.4%, P < 0.001) and injured via motor vehicle collision (23.2% versus 16.6%, P < 0.001) or gunshot wound (2.1% versus 1.3%, P < 0.001). HDD patients more often had extremity or torso injuries and after transfer were more likely to be transferred to the intensive care unit (35% versus 28.5%, P < 0.001), go directly to surgery (8.4% versus 5.9%, P < 0.001), or interventional radiology (0.8% versus 0.3%, P < 0.001). Overall mortality in the HDD group was 4.9% versus 2.1% in the group who remained stable. These results were confirmed using multivariable analysis. CONCLUSIONS: Interhospital transfers are essential in trauma, but one in 10 transferred patients deteriorated hemodynamically in that process. This high-risk component of the trauma system requires close attention to the important aspects of transfer such as patient selection, pretransfer management/stabilization, and communication between facilities.

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BACKGROUND: Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. METHODS: We used Pennsylvania Trauma Outcomes Study data, 2002 to 2021, and included EDTs for GSWs. We defined EDT by International Classification of Diseases codes for thoracotomy or procedures requiring one, with a location flagged as emergency department. We defined head injuries as any head Abbreviated Injury Scale (AIS) score of ≥1 and severe head injuries as head AIS score of ≥4. Head injuries were "isolated" if all other body regions have an AIS score of <2. Descriptive statistics were performed. Discharge functional status was measured in five domains. RESULTS: Over 20 years in Pennsylvania, 3,546 EDTs were performed; 2,771 (78.1%) were for penetrating injuries. Most penetrating EDTs (2,003 [72.3%]) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head injured (n = 94 of 1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound-0% (0 of 81) with a severe head injury ( p = 0.035 vs. no severe head injury) and 4.5% (5 of 110) with a nonsevere head injury. Of the five head-injured survivors, two were fully dependent for transfer mobility, and three were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. CONCLUSION: Although there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

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OBJECTIVE: Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time. BACKGROUND: EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition. METHODS: This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days. RESULTS: Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management. CONCLUSIONS: Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

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INTRODUCTION: Urban firearm violence (UFV) is associated with inequities rooted in structural racism and socioeconomic disparities. Social vulnerability index (SVI) is a composite measure that encompasses both. We sought to understand the relationship between SVI and the incidence of UFV in Chicago using geospatial analysis for the first time. MATERIALS AND METHODS: Firearm assaults in Chicago 2001-2019 were obtained from the Trace. Locations of incidents were geocoded using ArcGIS and overlaid with census tract vector files. These data were linked to 2018 SVI measures obtained from the Center for Disease Control and Prevention. Shooting rates were calculated by tabulating the total number of shootings per capita in each census tract. We used Poisson regression with robust error variance to estimate the incident rate of UFV in different levels of social vulnerability and Local Moran's I to evaluate spatial autocorrelation. RESULTS: In total, 642 census tracts were analyzed. The median shooting rate was 2.6 per 1000 people (interquartile 0.77, 7.0). When compared to those census tracts with very low SVI, census tracts with low SVI had a 1.7-time increased incident rate of shootings (incidence rate ratio [IRR] 1.74, 95% CI 1.08, 2.81), tracts with moderate SVI had a 3.1-time increased incident rate (IRR 3.07, 95% CI 2.31, 4.10), and tracts with high SVI had a 7-time increased incident rate (IRR 7.03, 95% CI 5.45, 9.07). CONCLUSIONS: In Chicago, social vulnerability has a significant association with rates of firearm violence, providing a focus point for policy intervention to address high rates of interpersonal violence in similar cities.

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BACKGROUND: Trauma is an episodic, chronic disease with substantial, long-term physical, psychological, emotional, and social impacts. However, the effect of recurrent trauma on these long-term outcomes remains unknown. We hypothesized that trauma patients with a history of prior traumatic injury (PTI) would have poorer outcomes 6 months (6mo) after injury compared with patients without PTI. METHODS: Adult trauma patients admitted at an urban, academic, Level I trauma center were screened for inclusion (October 2020 to November 2021). Enrolled patients were administered the PROMIS-29 instrument, the primary care post-traumatic stress disorder screen, and standardized questions about prior trauma hospitalization, substance use, employment, and living situation at baseline and 6mo after injury. Assessment data was merged with clinical registry data, and outcomes were compared with respect to PTI. RESULTS: Of 3,794 eligible patients, 456 completed baseline assessments and 92 completed 6mo surveys. Between those with or without PTI, there were no differences at 6mo after injury in the proportion of patients reporting poor function in social participation, anxiety, depression, fatigue, pain interference, or sleep disturbance. Prior traumatic injury patients reported poor physical function less often than patients without PTI (10 [27.0%] vs. 33 [60.0%], p = 0.002). After controlling for age, gender, race, injury mechanism, and Injury Severity Score, PTI correlated with a fourfold decrease in poor physical function risk (adjusted odds ratio, 0.243; 95% confidence interval, 0.081-0.733; p = 0.012) in the multivariable logistic regression model. CONCLUSION: Compared with patients suffering their first injury, trauma patients with PTI have better self-reported physical function after a subsequent injury and otherwise equivalent outcomes across a range of HRQoL domains at 6mo. There remains substantial room for improvement to mitigate the long-term challenges faced by trauma patients and to facilitate their societal reintegration, regardless of the number of times they are injured. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

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BACKGROUND: Recent political movements have raised questions about the effectiveness of police funding, but the impact of law enforcement budgets on firearm violence is unknown. We hypothesized that department funding and measures of police activity would be associated with decreased shootings and firearm homicides (FHs) in two major cities with different police funding patterns. METHODS: We collected data from the following sources: district attorney's offices, police departments, Federal Bureau of Investigation Uniform Crime Reporting program, the Centers for Disease Control, the Annual Survey of Public Employment and Payroll, and the American Community Survey. Data included demographics, police department budgets, number of officers, homicide clearance rates, firearms recovered, shootings, and FHs, 2015 to 2020. Totals were normalized to population and number of shootings. We used panel linear regression to measure associations between policing variables, shootings, and FHs while adjusting for covariates. RESULTS: Firearm homicides significantly increased in Philadelphia. In Boston, the trend was less clear, although there was an increase in 2020. Police budget normalized to shootings trended toward a decrease in Philadelphia and an increase in Boston. The number of firearms recovered annually appeared to increase in Boston but peaked midstudy in Philadelphia. In multivariable analyses, police budget was associated with neither shootings nor FHs. However, increased firearm recovery was associated with lower shooting ( ß = -0.0004, p = 0.022) and FH ( ß = -0.00005, p = 0.004) rates. CONCLUSION: Philadelphia and Boston demonstrated differences in police funding, 2015 to 2020. While budget is not associated with shootings or FHs, firearm recovery is suggesting that removal of firearms from circulation remains key. The impact this has on vulnerable populations requires further investigation. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

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INTRODUCTION: Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken. METHODS: Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes. RESULTS: One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation. CONCLUSIONS: Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.

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INTRODUCTION: Injured patients presenting in shock are at high risk of mortality despite numerous efforts to improve resuscitation. Identifying differences in outcomes among centers for this population could yield insights to improve performance. We hypothesized that trauma centers treating higher volumes of patients in shock would have lower risk-adjusted mortality. METHODS: We queried the Pennsylvania Trauma Outcomes Study from 2016 to 2018 for injured patients ≥16 years of age at Level I&II trauma centers who had an initial systolic blood pressure (SBP) of <90 mmHg. We excluded patients with critical head injury (abbreviated injury score [AIS] head ≥5) and patients coming from centers with a shock patient volume of ≤10 for the study period. The primary exposure was tertile of center-level shock patient volume (low, medium, or high volume). We compared risk-adjusted mortality by tertile of volume using multivariable Cox proportional hazards model incorporating age, injury severity, mechanism, and physiology. RESULTS: Of 1,805 included patients at 29 centers, 915 (50.7%) died. The median annual shock trauma patient volume was 9 patients for low volume centers, medium 19.5, and high 37. Median ISS was higher at high volume compared to low volume centers (22 vs 18, p <0.001). Raw mortality was 54.9% at high volume centers, 46.7% for medium, and 42.9% for low. Time elapsed from arrival to emergency department (ED) to the operating room (OR) was lower at high volume than low volume centers (median 47 vs 78 min) p = 0.003. In adjusted analysis, hazard ratio for high volume centers (referenced to low volume) was 0.76 (95% CI 0.59-0.97, p = 0.030). CONCLUSION: After adjusting for patient physiology and injury characteristics, center-level volume is significantly associated with mortality. Future studies should seek to identify key practices associated with improved outcomes in high-volume centers. Furthermore, shock patient volume should be considered when new trauma centers are opened.

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BACKGROUND: Health care political action committees (HPACs) historically contribute more to candidates opposing firearm restrictions (FRs), clashing with their affiliated medical societies. These societies have increasingly emphasized the prevention of firearm violence and it is not known if recent contributions by their HPACs have aligned with their stated goals. We hypothesized that such HPACs still contribute similar amounts toward legislators up for reelection opposing FR. METHODS: We identified HPACs of medical societies endorsing one or both calls-to-action against firearm violence published in the Annals of Internal Medicine (2015, 2019). House of Representatives (HOR) votes on H.R.8, a background checks bill, were characterized from GovTrack. We compiled HPAC contributions between the H.R.8 vote and election to HOR members up for re-election from the National Institute on Money in Politics. Our primary outcome was total campaign contributions by H.R.8 stance. Secondary outcomes included percentage of politicians funded and total contributions. RESULTS: Nineteen societies endorsed one or both call-to-action articles. Three hundred eighty-five of 430 HOR members ran for reelection in 2020. Those endorsing H.R.8 (n = 226, 59%) received $2.8 M for $4,750 (interquartile range [IQR], $1000-$15,500) per candidate. Those opposing (n = 159, 41%) received $1.5 M for $2,500 (IQR, $0-$11,000) per candidate ( p = 0.0057). Health care political action committees donated toward a median of 20% (IQR, 7-28) of candidates endorsing H.R.8 and 9% (IQR, 4-22) of candidates opposing H.R.8 ( p = 0.0014). Those endorsing H.R.8 received 1,585 total contributions for a median of 3 (IQR, 1-10) contributions per candidate, while those opposing received 834 total contributions for a median of 2 (IQR, 0-7) contributions per candidate ( p = 0.0029). CONCLUSION: Politicians voting against background checks received substantial contributions toward reelection from the HPACs of societies advocating for firearm restrictions. However, this is the first study to suggest that HPAC's contributions have become more congruent with their respective societies. Further alignment of medical society goals and their HPAC political contributions could have a profound impact on firearm violence. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

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BACKGROUND: Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. METHODS: We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. RESULTS: In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. CONCLUSION: There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.

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OBJECTIVE: This study aims to identify modifiable factors related to firearm homicide (FH). SUMMARY BACKGROUND DATA: Many socioeconomic, legislative and behavioral risk factors impact FH. Most studies have evaluated these risk factors in isolation, but they coexist in a complex and ever-changing American society. We hypothesized that both restrictive firearm laws and socioeconomic support would correlate with reduced FH rates. METHODS: To perform our ecologic cross-sectional study, we queried the Centers for Disease Control (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) and Federal Bureau of Investigation (FBI) Uniform Crime Reporting (UCR) for 2013-2016 state FH data. We retrieved firearm access estimates from the RAND State-Level Firearm Ownership Database. Alcohol use and access to care data were captured from the CDC Behavioral Risk Factor Surveillance System (BRFSS). Detached youth rates, socioeconomic support data and poverty metrics were captured from US Census data for each state in each year. Firearm laws were obtained from the State Firearms Law Database. Variables with significant FH association were entered into a final multivariable panel linear regression with fixed effect for state. RESULTS: A total of 49,610 FH occurred in 2013-2016 (median FH rate: 3.9:100,000, range: 0.07-11.2). In univariate analysis, increases in concealed carry limiting laws ( P =0.012), detached youth rates ( P <0.001), socioeconomic support ( P <0.001) and poverty rates ( P <0.001) correlated with decreased FH. Higher rates of heavy drinking ( P =0.036) and the presence of stand your ground doctrines ( P =0.045) were associated with increased FH. Background checks, handgun limiting laws, and weapon access were not correlated with FH. In multivariable regression, increased access to food benefits for those in poverty [ß: -0.132, 95% confidence interval (CI): -0.182 to -0.082, P <0.001] and laws limiting concealed carry (ß: -0.543, 95% CI: -0.942 to -0.144, P =0.008) were associated with decreased FH rates. Allowance of stand your ground was associated with more FHs (ß: 1.52, 95% CI: 0.069-2.960, P <0.040). CONCLUSIONS: The causes and potential solutions to FH are complex and closely tied to public policy. Our data suggests that certain types of socioeconomic support and firearm restrictive legislation should be emphasized in efforts to reduce firearm deaths in America.

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Migration of a ballistic missile through the vasculature is rare but important to recognize. It can lead to diagnostic confusion and seemingly unexplainable bullet trajectories. We have described the case of a young man with a gunshot wound to the axillary vein and initial embolus to the inferior vena cava. The bullet subsequently migrated to the right common iliac vein, allowing for straightforward retrieval.

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BACKGROUND: Higher center-level operative volume is associated with lower mortality after complex elective surgeries, but this relationship has not been robustly demonstrated for operative trauma. We hypothesized that trauma centers in Pennsylvania with higher operative trauma volumes would have lower risk-adjusted mortality rates than lower volume institutions. METHODS: We queried the Pennsylvania Trauma Outcomes Study database (2017-2019) for injured patients 18 years or older at Level I and II trauma centers who underwent an International Classification of Diseases, Tenth Revision (ICD-10), procedure code -defined operative procedure within 6 hours of admission. The primary exposure was tertile of center-level operative volume. The primary outcome of interest was inpatient mortality. We entered factors associated with mortality in univariate analysis (age, injury severity, mechanism, physiology) into multivariable logistic regression models with tertiles of volume accounting for center-level clustering. We conducted secondary analyses varying the form of the association between the volume and mortality to including dichotomous and fractional polynomial models. RESULTS: We identified 3,650 patients at 29 centers meeting the inclusion criteria. Overall mortality was 15.9% (center-level range, 6.7-34.2%). Operative procedure types were cardiopulmonary (7.3%), vascular (20.1%), abdominopelvic (24.3%), and multiple (48.3%). The mean annual operative volume over the 3 years of data was 10 to 21 operations for low-volume centers, 22 to 47 for medium-volume centers, and 47 to 158 for high-volume centers. After controlling for patient demographics, physiology, and injury characteristics, there was no significant difference in mortality between highest and lowest tertile centers (odds ratio, 0.92; confidence interval, 0.57-1.49). Secondary analyses similarly demonstrated no relationship between center operative volume and mortality in key procedure subgroups. CONCLUSION: In a mature trauma system, we found no association between center-level operative volume and mortality for patients who required early operative intervention for trauma. Efforts to standardize the care of seriously injured patients in Pennsylvania may ensure that even lower-volume centers are prepared to generate satisfactory outcomes. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

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