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Table. Data on 30-Day MACE Rates and 1-Year Mortality

Patients, No. (%)


30-d MACE Rate 1-y Mortality
Characteristic Total No. Yes No P Value Yes No P Value
Overall 636 37 (5.9) 595 (94.1) 61 (9.7) 571 (90.3)
Surgery type
Colon 550 36 (6.5) 514 (93.5) 54 (9.8) 496 (90.2)
.06 .71
Rectal 82 1 (1.2) 81 (98.8) 7 (8.5) 75 (91.5)
Cardiac risk comorbidities
Prior stress test
Yes 164 15 (9.1) 149 (90.9) 22 (13.4) 142 (86.6)
.04 .06
No 468 22 (4.7) 446 (95.3) 39 (8.3) 429 (91.7)
RCRI
2 375 17 (4.5) 358 (95.5) 17 (4.5) 358 (95.5)
.09 <.001
3 257 20 (7.8) 237 (92.2) 44 (17.1) 213 (82.9)
CHF within 1 mo 24 3 (12.5) 21 (87.5) .16 6 (25.0) 18 (75.0) .01
Surgery characteristics
Liver biopsy
Yes 30 3 (10.0) 27 (90.0) 8 (26.7) 22 (73.3)
.32 .001
No 602 34 (5.6) 568 (94.4) 53 (8.8) 549 (91.2)
Stent characteristics
Time of stent placement
After colonoscopy 70 7 (10.0) 63 (90.0) 10 (14.3) 60 (85.7)
Before colonoscopy 126 9 (7.1) 117 (92.9) .18 10 (7.9) 116 (92.1) .34
No stent 436 21 (4.8) 415 (95.2) 41 (9.4) 395 (90.6)
Stent indication
No stent 436 21 (4.8) 415 (95.2) 41 (9.4) 295 (90.6)
Non-ACS 90 5 (5.6) 85 (94.4) .09 9 (10.0) 81 (90.0) .95
ACS 106 11 (10.4) 95 (89.6) 11 (10.4) 95 (89.6)
Interval, median (IQR), d
From colonoscopy to surgery 41 (20-112) 48 (22-94) .91 52 (14-109) 47 (23-92) .91
From stent placement to surgery 142 (27-422) 191 (61-439) .25 92 (47-415) 191 (59-439) .31
From stent placement to colonoscopya 66 (17 to 338) 103 (31 to 387) .86 5 (14 to 301) 109 (28 to 388) .30
a
Abbreviations: ACS, acute coronary syndrome; CHF, congestive heart failure; A negative value for the interval from stent placement to colonoscopy
IQR, interquartile range; MACE, major adverse cardiac event; RCRI, Revised indicates that the stent was placed after the colonoscopy.
Cardiac Risk Index.

Administrative, technical, or material support: Holcomb, Graham. 3. Simunovic M, Rempel E, Thriault ME, et al. Influence of delays to
Study supervision: Hawn. nonemergent colon cancer surgery on operative mortality, disease-specific
Conflict of Interest Disclosures: None reported. survival and overall survival. Can J Surg. 2009;52(4):E79-E86.

Funding/Support: This study is supported by a Department of Veterans Affairs 4. Holcomb CN, Graham LA, Richman JS, Itani KM, Maddox TM, Hawn MT. The
Health Services Research and Development Grant (IIR 09-347). Dr Holcomb is incremental risk of coronary stents on postoperative adverse events: a matched
supported by grant T32 HS013852-11 from the Agency for Healthcare Research cohort study [published online April 17, 2015]. Ann Surg. doi:10.1097/SLA
and Quality. Dr Richman is supported by a Department of Veterans Affairs .0000000000001246.
Career Development Award. 5. Jackson GL, Melton LD, Abbott DH, et al. Quality of nonmetastatic colorectal
Role of the Funder/Sponsor: The Department of Veterans Affairs had no role in cancer care in the Department of Veterans Affairs. J Clin Oncol. 2010;28(19):
the design and conduct of the study; collection, management, analysis, or 3176-3181.
interpretation of the data; preparation, review, or approval of the manuscript; 6. Paulson EC, Fu X, Epstein AJ. Location and timing of care for colon cancer
and decision to submit the manuscript for publication. patients in the VA Health System. J Surg Res. 2013;183(2):639-644.
Previous Presentation: This paper was presented at the 39th Annual Meeting
of the Association of VA Surgeons; May 3, 2015; Miami Beach, Florida.
ASSOCIATION OF VA SURGEONS
1. Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of
Cardiology; American Heart Association. 2014 ACC/AHA guideline on Helmet Use and Injury Patterns
perioperative cardiovascular evaluation and management of patients in Motorcycle-Related Trauma
undergoing noncardiac surgery: a report of the American College of
Wearing a motorcycle helmet has been shown to decrease the
Cardiology/American Heart Association Task Force on practice guidelines. J Am
Coll Cardiol. 2014;64(22):e77-e137. number of injuries and the mortality rate associated with mo-
2. Iversen LH, Antonsen S, Laurberg S, Lautrup MD. Therapeutic delay reduces torcycle-related trauma.1 Once almost universal, many states
survival of rectal cancer but not of colonic cancer. Br J Surg. 2009;96(10):1183-1189. have regressed to partial or no helmet laws.2 This changing leg-

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Letters

Table 1. Demographics of Patients With Motorcycle-Related Trauma Table 2. Motorcycle-Related Trauma Outcome Metrics and Procedures
and Injury Patterns From the 2007-2010 National Trauma Database by ICD-9 Subgroup from the 2007-2010 National Trauma Database

Patients, % Riders
Patients,
Variable Total No. Helmeted Unhelmeted P Value Variable Helmeted Unhelmeted P Value
Sex No surgery, mean, d
Male 74 359 66.15 33.85 LOS 3.8 4.2 <.001
<.001
Female 11 330 61.82 38.18 ICU stay 4.24 4.33 <.001
Race
Ventilation 5.44 4.92 <.001
White 67 011 65.47 34.53
Surgery, mean, d
African American 7173 66.3 33.7
LOS 10.31 11.2 <.001
Asian 1049 69.88 30.12 .004
ICU stay 8.16 8.62 <.001
Other 6024 64.54 35.46
Ventilation 8.26 8.65 <.001
Hispanic or Latino 6101 59.65 40.35
Type or location of procedure,
Primary payer % of patients
Government related 11 614 63.04 36.96 Orthopedic 35.70 30.05 <.001
Private insurance 43 043 68.68 31.32
<.001 Skin 19.63 28.27 <.001
Self-pay 13 162 58.13 41.87
Vascular 10.79 14.35 <.001
Other 1795 65.22 34.78
Chest 8.37 8.28 .65
Alcohol use disorder
Bladder 5.46 8.98 <.001
No 80 425 66.87 33.13
<.001 Other abdominal area 3.14 2.91 <.001
Yes 5289 45.91 54.09
Lung 2.48 3.53 <.001
Current smoker
No 78 128 66.64 33.36 Stomach 2.05 3.81 <.001
<.001 Skull 1.32 3.33 <.001
Yes 7586 45.41 54.59
Injury area, AIS score Splenectomy 1.59 1.32 .002
Head and neck 0 61.05 36.09 Intestine 1.42 1.45 .73
1-2 22.06 32.45 <.001 Cervical spine 0.83 0.96 .07
3-6 16.89 31.36 Hand 0.60 0.61 .95
Trunk 0 52.24 57.95 Liver 0.43 0.41 .69
1-2 16.77 15.05 <.001 Renal 0.15 0.13 .41
3-6 30.99 27.00 Hernia repair 0.12 0.10 .35
Spine 0 77.37 78.93
Esophagus 0.10 0.10 .83
1-2 20.69 19.45 <.001
Pancreas 0.09 0.09 .66
3-6 1.94 1.62
Ureter 0.02 0.01 .39
Extremity 0 19.82 29.54
Heart 0.01 0.01 .71
1-2 59.25 53.34 <.001
3-6 20.93 17.12 Abbreviations: ICD-9, International Classification of Diseases, Ninth Revision;
ICU, intensive care unit; LOS, length of stay.
Mortality rate 3.84 6.01 <.001

Abbreviation: AIS, Abbreviated Injury Scale.

gery. Independent variables included helmeted vs unhel-


islation has provided opportunities for study that clearly in- meted rider, ethnicity, sex, alcohol abuse, and tobacco use. The
dicate the reduction in mortality benefit of helmet use. Al- Abbreviated Injury Scale score was used to evaluate patterns
though beneficial, helmet use could possibly lead to changes of injury in 4 areas: head and neck, trunk, spine, and extremi-
in injury patterns that have been previously undescribed. Using ties. The outcome variables were the total length of stay, the
data from the National Trauma Database, we performed a com- number of days in the intensive care unit, and the number of
parative analysis to evaluate the injury patterns, surgical in- days on a ventilator. Statistical evaluation was performed using
dications, and costs of hospital admission for helmeted and SAS version 9.3 (SAS Institute). The National Trauma Data-
unhelmeted riders. base contains deidentified data and does not require institu-
tional review board approval.
Methods | The 2007-2010 National Trauma Database was used
to identify patients with motorcycle-related trauma via Inter- Results | Alcohol abuse and tobacco use are both indepen-
national Classification of Diseases, Ninth Revision (ICD-9) codes dently correlated with a decrease in helmet use. Those with
(E-codes E810-E819, fourth digit 2 or 3). A total of 85 689 pa- private insurance had the highest percentage of helmet use,
tients were identified; those who died were not excluded. The with self-pay patients being the highest percentage of unhel-
ICD-9 codes were used to identify patients who underwent sur- meted riders (Table 1).

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The Abbreviated Injury Scale scores of subgroups of pa- Author Affiliations: Department of Surgery, Indiana University,
tients were used to evaluate patterns of injury for helmeted Indianapolis (Lastfogel); Department of Surgery, Division of Plastic Surgery,
Indiana University, Indianapolis (Soleimani, Wooden, Tholpady); Department
and unhelmeted riders. As expected, the incidence of head in- of Plastic Surgery, New York University, New York (Flores); Richard L.
jury was higher among the unhelmeted riders (63.81%) than Roudebush VA Medical Center, Indianapolis, Indiana (Cohen, Munshi,
among the helmeted riders (38.95%). In comparison, hel- Tholpady).
meted riders had higher rates of thoracic injury (47.76%) and Corresponding Author: Sunil S. Tholpady, MD, PhD, Department of Surgery,
Division of Plastic Surgery, Indiana University, 705 Riley Hospital Dr, RI 2514,
extremity injury (80.18%) than did unhelmeted riders (42.05%
Indianapolis, IN 46202 (stholpad@iupui.edu).
and 70.46%, respectively) (Table 1).
Published Online: October 21, 2015. doi:10.1001/jamasurg.2015.3225.
Differences in total length of stay, number of days in the
Author Contributions: Drs Tholpady and Lastfogel had full access to all of the
intensive care unit, and number of days on a ventilator were data in the study and take responsibility for the integrity of the data and the
small. Unhelmeted riders in both categories had slightly lon- accuracy of the data analysis.
ger lengths of stay and increased numbers of days in the in- Study concept and design: Lastfogel, Soleimani, Flores, Cohen, Wooden,
Tholpady.
tensive care unit (Table 2).
Acquisition, analysis, or interpretation of data: Lastfogel, Soleimani, Wooden,
The ICD-9 procedure codes were used to capture the num- Munshi, Tholpady.
ber of patients requiring surgical therapy in various catego- Drafting of the manuscript: Lastfogel, Wooden, Tholpady.
ries. Orthopedic procedures were the most common surgical Critical revision of the manuscript for important intellectual content: Soleimani,
Flores, Cohen, Munshi, Tholpady.
indication, with helmeted riders undergoing more orthope-
Statistical analysis: Lastfogel, Soleimani, Tholpady.
dic procedures than unhelmeted riders (35.7% vs 30.0%). A Administrative, technical, or material support: Munshi, Tholpady.
greater percentage of unhelmeted riders required surgery in Study supervision: Flores, Wooden, Tholpady.
most of the other categories evaluated (Table 2). Conflict of Interest Disclosures: None reported.
Previous Presentation: This paper was presented at the 39th Annual Meeting
Discussion | In the present study, alcoholism and tobacco use of the Association of VA Surgeons; May 4, 2015; Miami Beach, Florida.
were both independently associated with a decrease in hel- 1. US Dept of Transportation; National Highway Traffic Safety Administration.
Countermeasures That Work: A Highway Safety Countermeasure Guide for State
met use. This correlation has been shown in previous studies.3,4
Highway Safety Offices. 6th ed. Washington, DC: National Highway Traffic Safety
Unhelmeted riders were more likely to either self-pay or be cov- Administration; 2011.
ered under government insurance. These trends may reflect 2. McSwain NE Jr, Belles A. Motorcycle helmetsmedical costs and the law.
a tendency to engage in high-risk behavior while either ignor- J Trauma. 1990;30(10):1189-1197.
ing or dismissing the potential consequences of these 3. Luna GK, Maier RV, Sowder L, Copass MK, Oreskovich MR. The influence of
actions. ethanol intoxication on outcome of injured motorcyclists. J Trauma. 1984;24(8):
695-700.
The data on the Abbreviated Injury Scale scores indi-
4. Nelson D, Sklar D, Skipper B, McFeeley PJ. Motorcycle fatalities in New
cated that helmeted riders had a higher number of injuries to
Mexico: the association of helmet nonuse with alcohol intoxication. Ann Emerg
the spine, trunk, and extremities and had significantly more Med. 1992;21(3):279-283.
orthopedic procedures. One possible explanation for this is that
helmeted riders are surviving higher-force impacts than un-
helmeted riders and are thus presenting with more extensive Optical Biopsy of Bladder Cancer Using
injuries. Helmet use itself may be a factor in contributing to Crowd-Sourced Assessment
high-impact collisions because a helmeted riders increased Crowdsourcing and optical biopsy are emerging technologies
sense of security may result in a proclivity for higher speeds. with broad applications in clinical medicine and research.
Owing to their significantly higher rate of head injury, un- Crowdsourcing, an interactive digital platform that uses mul-
helmeted patients are expected to have a markedly increased tiple individual contributions to efficiently perform a com-
length of stay; however, the higher rates of other injuries among plex task, has been successfully used in diverse disciplines
the helmeted group resulted in only slightly longer lengths of ranging from performance assessment in surgery to optimi-
stay for unhelmeted patients. Nevertheless, the current trends zation of tertiary protein conformations.1,2 Optical biopsy tech-
toward bundled reimbursements and patient-guided satisfac- nologies provide real-time tissue imaging with histology-like
tion metrics imply increased costs for even small differences resolution and the potential to guide intraoperative decision
in time of care. Given the change in injury patterns from the making.3-5 An example is confocal laser endomicroscopy (CLE),
head to the rest of the body as a result of helmet use, updated which can be used for the diagnosis and grading of bladder
recommendations for the use of supplemental protective gear cancer.6 To further assess the adoptability of optical biopsy as
could be beneficial to both the individual and the health care a diagnostic tool, we applied crowdsourcing to determine the
system. barriers to learning how to diagnose cancer using CLE. We hy-
pothesized that a nonmedically trained crowd could learn to
Jeff Lastfogel, MD, MBA rapidly and accurately distinguish between cancer and be-
Tahereh Soleimani, MD nign tissue.
Roberto Flores, MD
Adam Cohen, MD Methods | Amazon Mechanical Turk (Amazon.com) users
William A. Wooden, MD were recruited as the crowd using a software platform
Imtiaz Munshi, MD, MBA developed by C-SATS. Each crowd worker first completed a
Sunil S. Tholpady, MD, PhD validated training module6 and answered a standard screen-

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