General surgery resident (2017-2025; administrative chief resident 2024-2025). MS in Epidemiology & Clinical Research (2019-2020), and Biomedical Informatics (2020-2022). Ex-president of Surgeons Writing About Trauma. Founding course instructor of SURG238: Practical Introduction to Surgical Research.

My research vision is to save or better the most possible number of lives using data. Our group focuses on:

1) building and implementing useful clinical prediction tools
2) bringing various AI applications (e.g. NLP, vision) to the bedside
3) challenging dogma in surgical practice with contemporary data

My passions are advocating for higher statistical and machine learning methodology quality in surgical literature , and fostering the growth of the next generation of surgeon data scientists.

Honors & Awards

  • 2nd Place, Resident Research Competition, Pacific Coast Surgical Association (2023)
  • Reviewer of the Month, Journal of Trauma and Acute Care Surgery (2023)
  • Division of General Surgery Resident Professional Development Award, Stanford Department of Surgery (2020, 2021)
  • CWIS-KLS Martin Resident Research Fellowship in Chest Wall Injury Outcomes, Chest Wall Injury Society (2020)
  • Neil and Claudia Doerhoff Scholar, Neil and Claudia Doerhoff fund (2019)
  • Travel Scholarship, American Association for the Surgery of Trauma (2018)
  • Vascular Surgery Intern of the Year, Stanford Department of Surgery (2018)
  • Best Medical Student Research Award, Emile F. Holman Lecture & Research Day (2017)
  • Trainee Award, Technological Innovations in Immunology, American Association of Immunologists (2016)
  • Best Basic Science Research, World Korean Medical Organization (2014)
  • Best Cultural Essay, World Korean Medical Organization (2014)
  • Medical Scholars Award, Stanford University School of Medicine (2014)
  • Young Innovator Award, American Society of Transplantation (2014)

Boards, Advisory Committees, Professional Organizations

  • Associate Member Council, American Association for the Surgery of Trauma (2023 - Present)
  • Chair, Scholarship and Development Committee, American Association for the Surgery of Trauma- Associate Members (2023 - Present)
  • Manuscript and Literature Review Committee, Eastern Association for the Surgery of Trauma (2023 - Present)
  • Healthcare Economics Committee, American Association for the Surgery of Trauma (2023 - Present)
  • Publications Committee, Chest Wall Injury Society (2022 - Present)
  • Research Committee, Chest Wall Injury Society (2021 - Present)

Membership Organizations

Professional Education

  • Internship (General Surgery), Stanford University

All Publications

  • Pediatric Trauma Center Access, Regional Injury Burden, and Socioeconomic Disadvantage. JAMA surgery Hur, D. G., Ren, A. L., Yue, T. M., Spain, D. A., Choi, J. 2024

    View details for DOI 10.1001/jamasurg.2024.0962

    View details for PubMedID 38748438

  • Career Trajectory After General Surgery Residency: Do Academic Program Graduates Pursue Academic Surgery? Annals of surgery Green, A., Sommer, E. R., Johnson, M. R., Gonzalez, H., Sia, T., Spain, D. A., Choi, J. 2024


    Determine the proportion of contemporary US academic general surgery residency program graduates who pursue academic careers and identify factors associated with pursuing academic careers.Many academic residency programs aim to cultivate academic surgeons, yet the proportion of contemporary graduates who choose academic careers is unclear. The potential determinants that affect graduates' decisions to pursue academic careers remain underexplored.We collected program and individual-level data on 2015 and 2018 graduates across 96 US academic general surgery residency programs using public resources. We defined those pursuing academic careers as faculty within US allopathic medical school-affiliated surgery departments who published two or more peer-reviewed publications as the first or senior author between 2020-2021. After variable selection using sample splitting LASSO regression, multivariable regression evaluated association with pursuing academic careers among all graduates, and graduates of top-20 residency programs. Secondary analysis using multivariable ordinal regression explored factors associated with high research productivity during early faculty years.Among 992 graduates, 166 (17%) were pursuing academic careers according to our definition. Graduating from a top-20 ranked residency program (OR[95%CI]: 2.34[1.40-3.88]), working with a longitudinal research mentor during residency (OR[95%CI]: 2.21[1.24-3.95]), holding an advanced degree (OR[95%CI]: 2.20[1.19-3.99]), and the number of peer-reviewed publications during residency as first or senior author (OR[95%CI]: 1.13[1.07-1.20]) were associated with pursuing an academic surgery career, while the number of peer-reviewed publications before residency was not (OR[95%CI]: 1.08[0.99-1.20]). Among top 20 program graduates, working with a longitudinal research mentor during residency (OR[95%CI]: 0.95[0.43-2.09]) was not associated with pursuing an academic surgery career. The number of peer-reviewed publications during residency as first or senior author was the only variable associated with higher productivity during early faculty years (OR[95%CI]: 1.12[1.07-1.18]).Our findings suggest programs that aim to graduate academic surgeons may benefit from ensuring trainees receive infrastructural support and demonstrate sustained commitment to research throughout residency. Our results should be interpreted cautiously as the impact of unmeasured confounders is unclear.

    View details for DOI 10.1097/SLA.0000000000006307

    View details for PubMedID 38652655

  • Access to Burn Care in the US. JAMA surgery Hur, D. G., Yao, J., Yue, T. M., Sheckter, C. C., Choi, J. 2024


    This cross-sectional study examines burn incidence rates and accessibility of American Burn Association-verified or self-designated burn centers from 2013 to 2019.

    View details for DOI 10.1001/jamasurg.2023.7763

    View details for PubMedID 38353985

  • Development and Validation of a Model to Quantify Injury Severity in Real Time. JAMA network open Choi, J., Vendrow, E. B., Moor, M., Spain, D. A. 2023; 6 (10): e2336196


    Quantifying injury severity is integral to trauma care benchmarking, decision-making, and research, yet the most prevalent metric to quantify injury severity-Injury Severity Score (ISS)- is impractical to use in real time.To develop and validate a practical model that uses a limited number of injury patterns to quantify injury severity in real time through 3 intuitive outcomes.In this cohort study for prediction model development and validation, training, development, and internal validation cohorts comprised 223 545, 74 514, and 74 514 admission encounters, respectively, of adults (age ≥18 years) with a primary diagnosis of traumatic injury hospitalized more than 2 days (2017-2018 National Inpatient Sample). The external validation cohort comprised 3855 adults admitted to a level I trauma center who met criteria for the 2 highest of the institution's 3 trauma activation levels.Three outcomes were hospital length of stay, probability of discharge disposition to a facility, and probability of inpatient mortality. The prediction performance metric for length of stay was mean absolute error. Prediction performance metrics for discharge disposition and inpatient mortality were average precision, precision, recall, specificity, F1 score, and area under the receiver operating characteristic curve (AUROC). Calibration was evaluated using calibration plots. Shapley addictive explanations analysis and bee swarm plots facilitated model explainability analysis.The Length of Stay, Disposition, Mortality (LDM) Injury Index (the model) comprised a multitask deep learning model trained, developed, and internally validated on a data set of 372 573 traumatic injury encounters (mean [SD] age = 68.7 [19.3] years, 56.6% female). The model used 176 potential injuries to output 3 interpretable outcomes: the predicted hospital length of stay, probability of discharge to a facility, and probability of inpatient mortality. For the external validation set, the ISS predicted length of stay with mean absolute error was 4.16 (95% CI, 4.13-4.20) days. Compared with the ISS, the model had comparable external validation set discrimination performance (facility discharge AUROC: 0.67 [95% CI, 0.67-0.68] vs 0.65 [95% CI, 0.65-0.66]; recall: 0.59 [95% CI, 0.58-0.61] vs 0.59 [95% CI, 0.58-0.60]; specificity: 0.66 [95% CI, 0.66-0.66] vs 0.62 [95%CI, 0.60-0.63]; mortality AUROC: 0.83 [95% CI, 0.81-0.84] vs 0.82 [95% CI, 0.82-0.82]; recall: 0.74 [95% CI, 0.72-0.77] vs 0.75 [95% CI, 0.75-0.76]; specificity: 0.81 [95% CI, 0.81-0.81] vs 0.76 [95% CI, 0.75-0.77]). The model had excellent calibration for predicting facility discharge disposition, but overestimated inpatient mortality. Explainability analysis found the inputs influencing model predictions matched intuition.In this cohort study using a limited number of injury patterns, the model quantified injury severity using 3 intuitive outcomes. Further study is required to evaluate the model at scale.

    View details for DOI 10.1001/jamanetworkopen.2023.36196

    View details for PubMedID 37812422

  • TraumaICDBERT, A Natural Language Processing Algorithm to Extract Injury ICD-10 Diagnosis Code from Free Text. Annals of surgery Choi, J., Chen, Y., Sivura, A., Vendrow, E. B., Wang, J., Spain, D. A. 2023


    OBJECTIVE: To develop and validate TraumaICDBERT, a natural language processing algorithm to predict injury ICD-10 diagnosis codes from trauma tertiary survey notes.SUMMARY BACKGROUND DATA: The adoption of ICD-10 diagnosis codes in clinical settings for injury prediction is hindered by the lack of real-time availability. Existing natural language processing algorithms have limitations in accurately predicting injury ICD-10 diagnosis codes.METHODS: Trauma tertiary survey notes from hospital encounters of adults between January 2016 and June 2021 were used to develop and validate TraumaICDBERT, an algorithm based on BioLinkBERT. The performance of TraumaICDBERT was compared to Amazon Web Services Comprehend Medical, an existing natural language processing tool.RESULTS: A dataset of 3,478 tertiary survey notes with 15,762 4-character injury ICD-10 diagnosis codes was analyzed. TraumaICDBERT outperformed Amazon Web Services Comprehend Medical across all evaluated metrics. On average, each tertiary survey note was associated with 3.8 (standard deviation: 2.9) trauma registrar-extracted 4-character injury ICD-10 diagnosis codes.CONCLUSIONS: TraumaICDBERT demonstrates promising initial performance in predicting injury ICD-10 diagnosis codes from trauma tertiary survey notes, potentially facilitating the adoption of downstream prediction tools in clinical settings.

    View details for DOI 10.1097/SLA.0000000000006107

    View details for PubMedID 37753654

  • For-Profit Status and Geographic Distribution of Trauma Centers in the US. JAMA surgery Handley, T. J., Kang, A., Alawa, J., Arnow, K., Spain, D. A., Choi, J. 2023


    This cohort study assesses geographic distribution of for-profit and not-for-profit trauma centers in the US designated by their states between 2014 and 2018.

    View details for DOI 10.1001/jamasurg.2023.2751

    View details for PubMedID 37494053

  • Maturing as an Impactful Academic Surgeon during Residency Research Time. Annals of surgery Choi, J., Spain, D. A. 2022

    View details for DOI 10.1097/SLA.0000000000005766

    View details for PubMedID 36538632

  • Explainable Machine Learning to Bring Database to the Bedside: Development and Validation of the TROUT (Trauma fRailty OUTcomes) Index, a Point-of-Care Tool to Prognosticate Outcomes after Traumatic Injury based on Frailty. Annals of surgery Choi, J., Anderson, T., Tennakoon, L., Spain, D. A., Forrester, J. D. 2022


    Exemplify an explainable machine learning framework to bring database to the bedside; develop and validate a point-of-care frailty assessment tool to prognosticate outcomes after injury.A geriatric trauma frailty index that captures only baseline conditions, is readily-implementable, and validated nationwide remains underexplored. We hypothesized Trauma fRailty OUTcomes (TROUT) Index could prognosticate major adverse outcomes with minimal implementation barriers.We developed TROUT index according to Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis guidelines. Using nationwide US admission encounters of patients aged ≥65 years (2016-2017; 10% development, 90% validation cohorts), unsupervised and supervised machine learning algorithms identified baseline conditions that contribute most to adverse outcomes. These conditions were aggregated into TROUT Index scores (0-100) that delineate three frailty risk strata. After associative (between frailty risk strata and outcomes, adjusted for age, sex, and injury severity [as effect modifier]) and calibration analysis, we designed a mobile application to facilitate point-of-care implementation.Our study population comprised 1.6 million survey-weighted admission encounters. Fourteen baseline conditions and one mechanism of injury constituted the TROUT Index. Among the validation cohort, increasing frailty risk (low=reference group, moderate, high) was associated with stepwise increased adjusted odds of mortality (OR[95%CI]: 2.6[2.4-2.8], 4.3[4.0-4.7]), prolonged hospitalization (OR[95%CI]: 1.4[1.4-1.5], 1.8 [1.8-1.9]), disposition to a facility (OR[95%CI]: 1.4[1.4-1.5], 1.8[1.7-1.8]), and mechanical ventilation (OR[95%CI]: 2.3[1.9-2.7], 3.6[3.0-4.5]). Calibration analysis found positive correlations between higher TROUT Index scores and all adverse outcomes. We built a mobile application ("TROUT Index") and shared code publicly.The TROUT Index is an interpretable, point-of-care tool to quantify and integrate frailty within clinical decision-making among injured patients. The TROUT Index is not a stand-alone tool to predict outcomes after injury; our tool should be considered in conjunction with injury pattern, clinical management, and within institution-specific workflows. A practical mobile application and publicly-available code can facilitate future implementation and external validation studies.

    View details for DOI 10.1097/SLA.0000000000005649

    View details for PubMedID 35920568

  • Access to American College of Surgeons Committee on Trauma-Verified Trauma Centers in the US, 2013-2019. JAMA Choi, J., Karr, S., Jain, A., Harris, T. C., Chavez, J. C., Spain, D. A. 2022; 328 (4): 391-393

    View details for DOI 10.1001/jama.2022.8097

    View details for PubMedID 35881133

  • Access to American College of Surgeons Committee on Trauma-Verified Trauma Centers in the US, 2013-2019 JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Choi, J., Karr, S., Jain, A., Harris, T. C., Chavez, J. C., Spain, D. A. 2022; 328 (4): 391-393
  • The Need to Routinely Convert Emergency Cricothyroidotomy to Tracheostomy: A Systematic Review and Meta-Analysis. Journal of the American College of Surgeons Choi, J., Anderson, T. N., Sheira, D., Sousa, J., Borghi, J. A., Spain, D. A., Knowlton, L. M. 2022; 234 (5): 947-952


    BACKGROUND: Traditional surgical teaching advocates converting emergency cricothyroidotomies to tracheostomies to mitigate the risk of subglottic stenosis. A conversion procedure that may risk losing a tenuous airway should have clear benefits over risks. We aimed to evaluate the necessity of routine cricothyroidotomy to tracheostomy conversion by conducting a systematic review and meta-analysis of contemporary literature.STUDY DESIGN: We performed a systematic review of experimental and observational studies (published between January 1, 2008, and March 1, 2021) reporting hospital outcomes of adults aged ≥18 years who underwent emergency cricothyroidotomies or tracheostomies. We followed PRISMA guidelines and assessed quality of data using GRADE methodology. Meta-analysis pooled incidence of procedure-specific complications (bleeding, subglottic stenosis, and others) using Freeman-Tukey double arcsine transformation and sensitivity analysis addressed survival bias.RESULTS: A total of 18 studies including 1246 patients were analyzed. Incidence of bleeding (5 [1 to 11]% vs 3 [1 to 7]%), subglottic stenosis (0 [0 to 3]% vs 0 [0 to 0]%) and other complications (12 [8 to 16]% vs 13 [5 to 23]%) were similar among patients undergoing emergency cricothyroidotomy or tracheostomy. Sensitivity analysis evaluating the incidence of complications among only survivors found similar results. Only one study reported complications attributable to cricothyroidotomy to tracheostomy conversion.CONCLUSIONS: Subglottic stenosis, the main harm conversion seeks to avoid, appears to be a rare complication after cricothyroidotomy. We did not find evidence supporting routine need to convert cricothyroidotomies to tracheostomies; for many patients, conversion is unlikely to rectify complications attributable to emergency cricothyroidotomy. However, our findings cannot be generalized to patients who require prolonged or permanent airway cannulation. Providers should consider performing cricothyroidotomy to tracheostomy selectively when the benefits clearly outweigh the risks of disrupting a secured airway.

    View details for DOI 10.1097/XCS.0000000000000114

    View details for PubMedID 35426409

  • Clinical Prediction Tools in Trauma: Where Do We Go From Here? JAMA network open Choi, J., Forrester, J. D. 2022; 5 (1): e2145867

    View details for DOI 10.1001/jamanetworkopen.2021.45867

    View details for PubMedID 35099551

  • The Weight of Surgical Knowledge: Navigating Information Overload. Annals of surgery Choi, J., Stave, C., Spain, D. A. 2021

    View details for DOI 10.1097/SLA.0000000000005365

    View details for PubMedID 35129478

  • Prospective study of long-term quality-of-life after rib fractures. Surgery Choi, J., Khan, S., Sheira, D., Hakes, N. A., Aboukhater, L., Spain, D. A. 1800


    BACKGROUND: Long-term quality-of-life after rib fractures remains understudied. We aimed to evaluate quality-of-life of patients who had rib fractures 1 year after discharge. We hypothesized that patients with rib fractures, even as an isolated injury, have suboptimal long-term quality-of-life.METHODS: We prospectively enrolled adults admitted to our level 1 trauma center with acute rib fractures. Primary outcome was quality-of-life at 1 year after discharge, characterized using the revised trauma-specific quality-of-life questionnaire and a supplemental survey. Secondary analysis evaluated association between baseline frailty (measured using the Rib Fracture Frailty Index) and quality-of-life. Patients with low versus moderate frailty risk underwent full matching and linear mixed model analysis.RESULTS: We enrolled 139 patients, among whom 72 (52%) completed 1-year surveys. Patients reported excellent emotional well-being (median [interquartile range]: 4.8 [3.7-5.0]) and functional engagement (median [interquartile range]: 5.0 [4.3-5.0]) but poor physical well-being and recovery (median [interquartile range]: 3.2 [2.8-3.6]). Nearly 40% of patients reported some degree of rib pain, and 29% had not returned to preinjury working capacity. Patients with and without isolated rib fractures reported similar median revised trauma-specific quality-of-life scores. We did not find statistically significant association between low versus moderate frailty and any quality-of-life domain, but no patients in our cohort had high frailty risk and our study was underpowered to detect this association.CONCLUSION: Rib fractures are associated with suboptimal quality-of-life 1 year after discharge, even after isolated injury. Our sample size was limited, but our findings highlight persistent long-term consequences of rib fractures despite advances in inpatient management. Patients should be counseled on the potential for prolonged convalescence.

    View details for DOI 10.1016/j.surg.2021.11.026

    View details for PubMedID 34969527

  • Citation Inaccuracies in Influential Surgical Journals. JAMA surgery Choi, J., Gupta, A., Kaghazchi, A., Htwe, T. S., Baiocchi, M., Spain, D. A. 2021

    View details for DOI 10.1001/jamasurg.2021.1445

    View details for PubMedID 34037684

  • Practical Computer Vision Application to Compute Total Body Surface Area Burn: Reappraising a Fundamental Burn Injury Formula in the Modern Era. JAMA surgery Choi, J., Patil, A., Vendrow, E., Touponse, G., Aboukhater, L., Forrester, J. D., Spain, D. A. 2021


    Critical burn management decisions rely on accurate percent total body surface area (%TBSA) burn estimation. Existing %TBSA burn estimation models (eg, Lund-Browder chart and rule of nines) were derived from a linear formula and a limited number of individuals a century ago and do not reflect the range of body habitus of the modern population.To develop a practical %TBSA burn estimation tool that accounts for exact burn injury pattern, sex, and body habitus.This population-based cohort study evaluated the efficacy of a computer vision algorithm application in processing an adult laser body scan data set. High-resolution surface anthropometry laser body scans of 3047 North American and European adults aged 18 to 65 years from the Civilian American and European Surface Anthropometry Resource data set (1998-2001) were included. Of these, 1517 participants (49.8%) were male. Race and ethnicity data were not available for analysis. Analyses were conducted in 2020.The contributory %TBSA for 18 body regions in each individual. Mobile application for real-time %TBSA burn computation based on sex, habitus, and exact burn injury pattern.Of the 3047 individuals aged 18 to 65 years for whom body scans were available, 1517 (49.8%) were male. Wide individual variability was found in the extent to which major body regions contributed to %TBSA, especially in the torso and legs. Anterior torso %TBSA increased with increasing body habitus (mean [SD], 15.1 [0.9] to 19.1 [2.0] for male individuals; 15.1 [0.8] to 18.0 [1.7] for female individuals). This increase was attributable to increase in abdomen %TBSA (mean [SD], 5.3 [0.7] to 8.7 [1.8]) among male individuals and increase in abdomen (mean [SD], 4.6 [0.6] to 6.8 [1.7]) and pelvis (mean [SD], 1.5 [0.2] to 2.9 [0.9]) %TBSAs among female individuals. For most body regions, Lund-Browder chart and rule of nines estimates fell outside the population's measured interquartile ranges. The mobile application tested in this study, Burn Area, facilitated accurate %TBSA burn computation based on exact burn injury pattern for 10 sex and body habitus-specific models.Computer vision algorithm application to a large laser body scan data set may provide a practical tool that facilitates accurate %TBSA burn computation in the modern era.

    View details for DOI 10.1001/jamasurg.2021.5848

    View details for PubMedID 34817552

  • Rib Fracture Frailty Index: A Risk-Stratification Tool for Geriatric Patients with Multiple Rib Fractures. The journal of trauma and acute care surgery Choi, J., Marafino, B. J., Vendrow, E. B., Tennakoon, L., Baiocchi, M., Spain, D. A., Forrester, J. D. 2021


    Rib fractures are consequential injuries for geriatric patients (age ≥ 65 years). Although age and injury patterns drive many rib fracture management decisions, the impact of frailty-which baseline conditions affect rib fracture-specific outcomes-remains unclear for geriatric patients. We aimed to develop and validate the Rib Fracture Frailty (RFF) Index, a practical risk-stratification tool specific for geriatric patients with rib fractures. We hypothesized that a compact list of frailty markers can accurately risk stratify clinical outcomes after rib fractures.We queried nationwide US admission encounters of geriatric patients admitted with multiple rib fractures from 2016-2017. Partitioning-around-medoids clustering identified a development subcohort with previously-validated frailty characteristics. Ridge regression with penalty for multicollinearity aggregated baseline conditions most prevalent in this frail subcohort into RFF scores. Regression models with adjustment for injury severity, sex, and age assessed associations between frailty risk categories (low, medium, and high) and inpatient outcomes among validation cohorts (OR [95%CI]). We report results according to Transparent Reporting of Multivariable Prediction Model for Individual Prognosis guidelines.Development cohort (N = 55,540) cluster analysis delineated thirteen baseline conditions constituting the RFF Index. Among external validation cohort (N = 77,710), increasing frailty risk (low [reference group], moderate, high) was associated with stepwise worsening adjusted odds of mortality (1.5[1.2-1.7], 3.5 [3.0-4.0]), intubation (2.4[1.5-3.9], 4.7[3.1-7.5]), hospitalization ≥5 days (1.4[1.3-1.5], 1.8[1.7-2.0]), and disposition to home (0.6[0.5-0.6], 0.4[0.3-0.4]). Locally weighted scatterplot smoothing showed correlations between increasing RFF scores and worse outcomes.RFF Index is a practical frailty risk-stratification tool for geriatric patients with multiple rib fractures. The mobile app we developed may facilitate rapid implementation and further validation of RFF Index at the bedside.level III, prognostic study.

    View details for DOI 10.1097/TA.0000000000003390

    View details for PubMedID 34446653

  • Nationwide Cost-Effectiveness Analysis of Surgical Stabilization of Rib Fractures by Flail Chest Status and Age Groups. The journal of trauma and acute care surgery Choi, J., Mulaney, B., Laohavinij, W., Trimble, R., Tennakoon, L., Spain, D. A., Salomon, J. A., Goldhaber-Fiebert, J. D., Forrester, J. D. 2020


    SSRF is increasingly utilized to manage patients with rib fractures. Benefits of performing SSRF appear variable and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of surgical stabilization of rib fractures (SSRF) vs non-operative management among patients with rib fractures aged <65 vs ≥65 years, with vs without flail chest. We hypothesized that compared to non-operative management, SSRF is cost-effective only for patients with flail chest.This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared to non-operative management. We report quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios.Compared to non-operative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of $150,000/QALY gained. SSRF cost $25,338 and $123,377/QALY gained for those with flail chest aged <65 and ≥65 years, respectively. SSRF was not cost-effective for patients without flail chest; costing $172,704 and $243,758/QALY gained for those aged <65 and ≥65 years, respectively. One-way sensitivity analyses showed that under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest and non-operative management remained cost-effective for patients aged >65 without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients aged <65 with flail chest to 35% among patients aged ≥65 without flail chest.SSRF is cost effective for patients with flail chest. SSRF may be cost-effective in some patients without flail chest, but delineating these patients requires further study.level II.

    View details for DOI 10.1097/TA.0000000000003021

    View details for PubMedID 33559982

  • Safety of Foregoing Operation for Small Bowel Obstruction in the Virgin Abdomen: Systematic Review and Meta-Analysis. Journal of the American College of Surgeons Choi, J. n., Fisher, A. T., Mulaney, B. n., Anand, A. n., Carlos, G. n., Stave, C. D., Spain, D. A., Weiser, T. G. 2020


    Our objective was to assess the safety of foregoing surgery in patients without abdominopelvic surgery history presenting with small bowel obstruction (SBO). Classic dogma has counseled early surgical intervention for small bowel obstruction (SBO) in the virgin abdomen - patients without abdominopelvic surgery history - given their presumed higher risk of malignant or potentially catastrophic etiologies compared to those who underwent prior abdominal operations. The term virgin abdomen was coined before widespread use of computed tomography, which now elucidates many SBO etiologies. Despite recent efforts to re-evaluate clinical management standards, the prevalence of SBO etiologies in the virgin abdomen and the current management landscape (non-operative vs operative) in these patients remain unclear. Our random-effects meta-analysis of six studies including 442 patients found the prevalence of malignant etiologies in patients without abdominopelvic surgery history presenting with SBO varied from 7.7% [95% CI:3.0-14.1] to 13.4% [95% CI:7.6-20.3] on sensitivity analysis. Most malignant etiologies were not suspected prior to surgery. De novo adhesions (54%) were the most common etiology. Over half of patients underwent a trial of non-operative management, which often failed. Subgroups of patients likely have variable risk profiles for underlying malignant etiologies, yet no study had consistent follow-up data and we did not find convincing evidence that foregoing operative management altogether in this population can be generally recommended.

    View details for DOI 10.1016/j.jamcollsurg.2020.06.010

    View details for PubMedID 32574687

  • Surgical Stabilization of Rib Fracture to Mitigate Pulmonary Complication and Mortality: A Systematic Review and Bayesian Meta-Analysis. Journal of the American College of Surgeons Choi, J. n., Gomez, G. I., Kaghazchi, A. n., Borghi, J. A., Spain, D. A., Forrester, J. D. 2020

    View details for DOI 10.1016/j.jamcollsurg.2020.10.022

    View details for PubMedID 33212228

  • Pain Scores in Geriatric vs Nongeriatric Patients With Rib Fractures. JAMA surgery Choi, J. n., Khan, S. n., Zamary, K. n., Tennakoon, L. n., Spain, D. A. 2020

    View details for DOI 10.1001/jamasurg.2020.1933

    View details for PubMedID 32609366

  • Prospective Study of Short-Term Quality-of-Life After Traumatic Rib Fractures. The journal of trauma and acute care surgery Choi, J. n., Khan, S. n., Hakes, N. A., Carlos, G. n., Seltzer, R. n., Jaramillo, J. D., Spain, D. A. 2020


    Post-discharge convalescence after traumatic rib fractures remains unclear. We hypothesized that patients with rib fractures, even as an isolated injury, have associated poor QoL after discharge.We prospectively enrolled adult patients at our Level I trauma center with rib fractures between July 2019 and January 2020. We assessed QoL at 1 and 3-months after discharge using the Trauma-specific Quality-of-Life (T-QoL: 43-question survey evaluating five QoL domains on a four-point Likert scale. "4" indicates optimal and "1" worst QoL) and supplementary questionnaires. We used generalized estimating equations to assess T-QoL score trends over time and effect of age, sex, injury pattern, self-perceived injury severity, and injury severity score.We enrolled 139 patients (108 completed the first and 93 completed both surveys). Three months after discharge, 33% of patients were not working at pre-injury capacity and 7% were still using opioid analgesia. Suffering rib fractures most impacted recovery and resilience (T-QoL score, mean [robust standard error] at 1-month: 2.7[0.1], 3-months: 3.0[0.1]) and physical well-being domains (1-month: 2.5[0.1]; 3-months 2.9[0.1]). QoL improved over time across all domains. Compared with patients who perceived their injuries as mild/moderate, patients who perceived their injuries as severe/very severe reported worse T-QoL scores across all domains. In contrast, injury severity score did not affect QoL. Patients aged ≥65 years (-0.6[0.1]) and females (-0.6[0.2]) reported worse functional engagement compared with those aged ≤65 years and males, respectively.We found that patients with traumatic rib fractures experience suboptimal QoL after discharge. QoL improved over time, but even three months after discharge, patients reported challenges performing activities of daily living, slower-than-expected recovery, and not returning to work at pre-injury capacity. Perception of injury severity had a large effect on QoL. Patients with rib fractures may benefit from close short-term follow-up.Prognostic and Epidemiological LEVEL OF EVIDENCE: Level III.

    View details for DOI 10.1097/TA.0000000000002917

    View details for PubMedID 32925583

  • The burden of readmissions after rib fractures among older adults. Surgery Choi, J., Hur, D. G., Tennakoon, L., Spain, D. A., Staudenmayer, K. 2024


    The index hospitalization morbidity and mortality of rib fractures among older adults (aged ≥65 years) is well-known, yet the burden and risks for readmissions after rib fractures in this vulnerable population remain understudied. We aimed to characterize the burdens and etiologies associated with 3-month readmissions among older adults who suffer rib fractures. We hypothesized that readmissions would be common and associated with modifiable etiologies.This survey-weighted retrospective study using the 2017 and 2019 National Readmissions Database evaluated adults aged ≥65 years hospitalized with multiple rib fractures and without major extrathoracic injuries. The main outcome was the proportion of patients experiencing all-cause 3-month readmissions. We assessed the 5 leading principal readmission diagnoses overall and delineated them by index hospitalization discharge disposition (home or facility). Sensitivity analysis using clinical classification categories characterized readmissions that could reasonably represent rib fracture-related sequelae.In 2017, 25,092 patients met the inclusion criteria, with 20% (N = 4,894) experiencing 3-month readmissions. Six percent of patients did not survive their readmission. The 5 leading principal readmission diagnoses were sepsis (many associated with secondary diagnoses of pneumonia [41%] or urinary tract infections [41%]), hypertensive heart/kidney disease, hemothorax, pneumonia, and respiratory failure. In 2019, a comparable 3-month readmission rate of 23% and identical 5 leading diagnoses were found. Principal readmission diagnosis of hemothorax was associated with the shortest time to readmission (median [interquartile range]:9 [5-23] days). Among patients discharged home after index hospitalization, pleural effusion-possibly representing mischaracterized hemothorax-was among the leading principal readmission diagnoses. Some patients readmitted with a principal diagnosis of hemothorax or pleural effusion had these diagnoses at index hospitalization; a lower proportion of these patients underwent pleural fluid intervention during index hospitalization compared with readmission. On sensitivity analysis, 30% of 3-month readmissions were associated with principal diagnoses suggesting rib fracture-related sequelae.Readmissions are not infrequent among older adults who suffer rib fractures, even in the absence of major extrathoracic injuries. Future studies should better characterize how specific complications associated with readmissions, such as pneumonia, urinary tract infections, and delayed hemothoraces, could be mitigated.

    View details for DOI 10.1016/j.surg.2024.05.021

    View details for PubMedID 38880698

  • Serratus anterior plane block improves pain and incentive spirometry volumes in trauma patients with multiple rib fractures: a prospective cohort study. Trauma surgery & acute care open Sadauskas, V., Fofana, M., Brunson, D., Choi, J., Spain, D., Quinn, J. V., Duanmu, Y. 2024; 9 (1): e001183


    Rib fractures are common injuries associated with considerable morbidity, long-term disability, and mortality. Early, adequate analgesia is important to mitigate complications such as pneumonia and respiratory failure. Regional anesthesia has been proposed for rib fracture pain control due to its superior side effect profile compared with systemic analgesia. Our objective was to evaluate the effect of emergency physician-performed, ultrasound-guided serratus anterior plane block (SAPB) on pain and respiratory function in emergency department patients with multiple acute rib fractures.This was a prospective observational cohort study of adult patients at a level 1 trauma center who had two or more acute unilateral rib fractures. Eligible patients received a SAPB if an emergency physician trained in the procedure was available at the time of diagnosis. Primary outcomes were the absolute change in pain scores and percent change in expected incentive spirometry volumes from baseline to 3 hours after rib fracture diagnosis.38 patients met eligibility criteria, 15 received the SAPB and 23 did not. The SAPB group had a greater decrease in pain scores at 3 hours (-3.7 vs. -0.9; p=0.003) compared with the non-SAPB group. The SAPB group also had an 11% (CI 1.5% to 17%) increase in percent expected spirometry volumes at 3 hours which was significantly better than the non-SAPB group, which had a -3% (CI -9.1% to 2.7%) decrease (p=0.008).Patients with rib fractures who received SAPB as part of a multimodal pain control strategy had a greater improvement in pain and respiratory function compared with those who did not. Larger trials are indicated to assess the generalizability of these initial findings.

    View details for DOI 10.1136/tsaco-2023-001183

    View details for PubMedID 38881827

    View details for PubMedCentralID PMC11177771

  • Practical guide to building machine learning-based clinical prediction models using imbalanced datasets. Trauma surgery & acute care open Luu, J., Borisenko, E., Przekop, V., Patil, A., Forrester, J. D., Choi, J. 2024; 9 (1): e001222


    Clinical prediction models often aim to predict rare, high-risk events, but building such models requires robust understanding of imbalance datasets and their unique study design considerations. This practical guide highlights foundational prediction model principles for surgeon-data scientists and readers who encounter clinical prediction models, from feature engineering and algorithm selection strategies to model evaluation and design techniques specific to imbalanced datasets. We walk through a clinical example using readable code to highlight important considerations and common pitfalls in developing machine learning-based prediction models. We hope this practical guide facilitates developing and critically appraising robust clinical prediction models for the surgical community.

    View details for DOI 10.1136/tsaco-2023-001222

    View details for PubMedID 38881829

    View details for PubMedCentralID PMC11177772

  • Role of Vena Cava Filter in the Prophylaxis and Treatment of Venous Thromboembolism in Injured Adult Patients: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. The journal of trauma and acute care surgery Bhattacharya, B., Kodadek, L., Nichiporenko, I., Morrissey, S., Kirsch, J., Choi, J., Ladhani, H., Kasotakis, G., Mukherjee, K., Narsule, C., Sharma, R., Ruangvoravat, L., Grushka, J., Rattan, R., Bugaev, N. 2024


    Injured patients are at an increased risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE). Inferior vena cava (IVC) filters have been used in injured patients to prevent venous thromboembolism (VTE), but current evidence-based guidelines are lacking.Questions regarding IVC filter use in injured patients with clearly defined Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes (PICO) were formulated. The study sought to understand the evidence behind use of ultra short term IVC filters and use of IVC filters in injured patients with and without known VTE who are unable to receive therapeutic anticoagulation and chemoprophylaxis, respectively. A literature search and review was conducted, followed by meta-analysis. The quality of evidence was assessed per Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.There were twenty-one studies that were analyzed. Three studies were randomized controlled trials (RCTs), three were observational studies, and fifteen studies were retrospective studies. In injured patients without known acute VTE who cannot receive chemoprophylaxis, we recommend against placement of an IVC filter due to associated higher rate of mortality, DVT, PE, and length of stay. The quality of evidence was assessed to be low. In injured patients with known DVT who cannot receive chemoprophylaxis we conditionally recommend against placement of an IVC filter. The quality of evidence was assessed to be very low. No recommendations can be made with respect to placement of ultra short term IVC filters based upon available data.IVC filters should not be placed routinely for prophylaxis in injured adult patients without known VTE who cannot receive chemoprophylaxis. The taskforce conditionally recommends against the placement of IVC filter in injured adult patients with known DVT who cannot receive chemoprophylaxis.Guideline; Systematic review/meta-analysis, level IV.

    View details for DOI 10.1097/TA.0000000000004289

    View details for PubMedID 38454308

  • Thoracic and Lumbar Spine Injury: Evidence-Based Diagnosis, Management, and Outcomes. The American surgeon Gomez, G. I., Li, G. Q., Valido, A. A., Stoner, A. J., Bromley-Dulfano, R. A., Sheira, D., Gonzalez, C. A., Khan, S. I., Choi, J., Zygourakis, C. C., Weiser, T. G. 2023: 31348231216479


    Traumatic thoracolumbar spine injuries are associated with significant morbidity and mortality. Targeted for non-spine specialist trauma surgeons, this systematic scoping review aimed to examine literature for up-to-date evidence on presentation, management, and outcomes of thoracolumbar spine injuries in adult trauma patients.This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched four bibliographic databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. Eligible studies included experimental, observational, and evidence-synthesis articles evaluating patients with thoracic, lumbar, or thoracolumbar spine injury, published in English between January 1, 2010 and January 31, 2021. Studies which focused on animals, cadavers, cohorts with N <30, and pediatric cohorts (age <18 years old), as well as case studies, abstracts, and commentaries were excluded.A total of 2501 studies were screened, of which 326 unique studies were fully text reviewed and twelve aspects of injury management were identified and discussed: injury patterns, determination of injury status and imaging options, considerations in management, and patient quality of life. We found: (1) imaging is a necessary diagnostic tool, (2) no consensus exists for preferred injury characterization scoring systems, (3) operative management should be considered for unstable fractures, decompression, and deformity, and (4) certain patients experience significant burden following injury.In this systematic scoping review, we present the most up-to-date information regarding the management of traumatic thoracolumbar spine injuries. This allows non-specialist trauma surgeons to become more familiar with thoracolumbar spine injuries in trauma patients and provides a framework for their management.

    View details for DOI 10.1177/00031348231216479

    View details for PubMedID 37983195

  • Clinical prediction tool pitfalls and considerations: Data and algorithms. Surgery Choi, J., Marwaha, J. S. 2023


    In recent years, many surgical prediction models have been developed and published to augment surgeon decision-making, predict postoperative patient trajectories, and more. Collectively underlying all of these models is a wide variety of data sources and algorithms. Each data set and algorithm has its unique strengths, weaknesses, and type of prediction task for which it is best suited. The purpose of this piece is to highlight important characteristics of common data sources and algorithms used in surgical prediction model development so that future researchers interested in developing models of their own may be able to critically evaluate them and select the optimal ones for their study.

    View details for DOI 10.1016/j.surg.2023.08.009

    View details for PubMedID 37709646

  • An Open-Source Curriculum to Teach Practical Academic Research Skills. Annals of surgery open : perspectives of surgical history, education, and clinical approaches Lee, J. J., Korndorffer, J. R., Knowlton, L. M., Choi, J. 2023; 4 (3): e329


    Academic productivity is important for career advancement, yet not all trainees have access to structured research programs. Without formal teaching, acquiring practical skills for research can be challenging. A comprehensive research course that teaches practical skills to translate ideas into publications could accelerate trainees' productivity and liberate faculty mentors' time. We share our experience designing and teaching "A Practical Introduction to Academic Research", a course that teaches practical skills including building productive habits, recognizing common statistical pitfalls, writing cover letters, succinct manuscripts, responding to reviewers, and delivering effective presentations. We share open-source educational material used during the Winter 2022 iteration to facilitate curriculum adoption at peer institutions.

    View details for DOI 10.1097/AS9.0000000000000329

    View details for PubMedID 37746596

    View details for PubMedCentralID PMC10513130

  • Guest editor's introduction to the series. Surgery Choi, J. 2023

    View details for DOI 10.1016/j.surg.2023.05.025

    View details for PubMedID 37380570

  • Artificial Intelligence-enabled Decision Support in Surgery: State-of-the-art and Future Directions. Annals of surgery Loftus, T. J., Altieri, M. S., Balch, J. A., Abbott, K. L., Choi, J., Marwaha, J. S., Hashimoto, D. A., Brat, G. A., Raftopoulos, Y., Evans, H. L., Jackson, G. P., Walsh, D. S., Tignanelli, C. J. 2023


    To summarize state-of-the-art artificial intelligence-enabled decision support in surgery and to quantify deficiencies in scientific rigor and reporting.To positively affect surgical care, decision-support models must exceed current reporting guideline requirements by performing external and real-time validation, enrolling adequate sample sizes, reporting model precision, assessing performance across vulnerable populations, and achieving clinical implementation; the degree to which published models meet these criteria is unknown.Embase, PubMed, and MEDLINE databases were searched from their inception to September 21, 2022 for articles describing artificial intelligence-enabled decision support in surgery that uses preoperative or intraoperative data elements to predict complications within 90 days of surgery. Scientific rigor and reporting criteria were assessed and reported according to PRISMA-ScR guidelines.Sample size ranged from 163-2,882,526, with 8/36 articles (22.2%) featuring sample sizes of less than 2,000; seven of these eight articles (87.5%) had below-average (<0.83) area under the receiver operating characteristic (AUROC) or accuracy. Overall, 29 articles (80.6%) performed internal validation only, five (13.8%) performed external validation, and two (5.6%) performed real-time validation. Twenty-three articles (63.9%) reported precision. No articles reported performance across sociodemographic categories. Thirteen articles (36.1%) presented a framework that could be used for clinical implementation; none assessed clinical implementation efficacy.Artificial intelligence-enabled decision support in surgery is limited by reliance on internal validation, small sample sizes that risk overfitting and sacrifice predictive performance, and failure to report confidence intervals, precision, equity analyses, and clinical implementation. Researchers should strive to improve scientific quality.

    View details for DOI 10.1097/SLA.0000000000005853

    View details for PubMedID 36942574

  • FasterRib: A Deep Learning Algorithm to Automate Identification and Characterization of Rib Fractures on Chest Computed Tomography Scans. The journal of trauma and acute care surgery Edamadaka, S., Brown, D. J., Swaroop, R., Kolodner, M., Spain, D. A., Forrester, J. D., Choi, J. 2023


    Characterizing and enumerating rib fractures is critical to informing clinical decisions, yet in-depth characterization is rarely performed due to the manual burden of annotating these injuries on computed tomography (CT) scans. We hypothesized that our deep learning model, FasterRib, could predict the location and percentage displacement of rib fractures using chest CT scans.The development and internal validation cohort comprised over 4,700 annotated rib fractures from 500 chest CT scans within the public RibFrac. We trained a convolutional neural network to predict bounding boxes around each fracture per CT slice. Adapting an existing rib segmentation model, FasterRib outputs the three-dimensional locations of each fracture (rib number and laterality). A deterministic formula analyzed cortical contact between bone segments to compute percentage displacements. We externally validated our model on our institution's dataset.FasterRib predicted precise rib fracture locations with 0.95 sensitivity, 0.90 precision, 0.92 f1-score, with an average of 1.3 false positive fractures per scan. On external validation, FasterRib achieved 0.97 sensitivity, 0.96 precision, and 0.97 f1-score, and 2.24 false positive fractures per scan. Our publicly-available algorithm automatically outputs the location and percent displacement of each predicted rib fracture for multiple input CT scans.We built a deep learning algorithm that automates rib fracture detection and characterization using chest CT scans. FasterRib achieved the highest recall and the second highest precision among known algorithms in literature. Our open source code could facilitate FasterRib's adaptation for similar computer vision tasks and further improvements via large-scale external validation.Level III. Diagnostic tests/criteria.

    View details for DOI 10.1097/TA.0000000000003913

    View details for PubMedID 36872505

  • An Open-Source Curriculum to Teach Practical Academic Research Skills Annals of Surgery Open Lee, J. J., Korndorffer, J. R., Knowlton, L. M., Choi, J. 2023; 4 (3)
  • Appraising the Quality of Development and Reporting in Surgical Prediction Models. JAMA surgery Marwaha, J. S., Chen, H. W., Habashy, K., Choi, J., Spain, D. A., Brat, G. A. 2022

    View details for DOI 10.1001/jamasurg.2022.4488

    View details for PubMedID 36449299

  • Evidence-based surgery for laparoscopic cholecystectomy. Surgery open science Fisher, A. T., Bessoff, K. E., Khan, R. I., Touponse, G. C., Yu, M. M., Patil, A. A., Choi, J., Stave, C. D., Forrester, J. D. 2022; 10: 116-134


    Laparoscopic cholecystectomy is frequently performed for acute cholecystitis and symptomatic cholelithiasis. Considerable variation in the execution of key steps of the operation remains. We conducted a systematic review of evidence regarding best practices for critical intraoperative steps for laparoscopic cholecystectomy.We identified 5 main intraoperative decision points in laparoscopic cholecystectomy: (1) number and position of laparoscopic ports; (2) identification of cystic artery and duct; (3) division of cystic artery and duct; (4) indications for subtotal cholecystectomy; and (5) retrieval of the gallbladder. PubMed, EMBASE, and Web of Science were queried for relevant studies. Randomized controlled trials and systematic reviews were included for analysis, and evidence quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation framework.Fifty-two articles were included. Although all port configurations were comparable from a safety standpoint, fewer ports sometimes resulted in improved cosmesis or decreased pain but longer operative times. The critical view of safety should be obtained for identification of the cystic duct and artery but may be obtained through fundus-first dissection and augmented with cholangiography or ultrasound. Insufficient evidence exists to compare harmonic-shear, clipless ligation against clip ligation of the cystic duct and artery. Stump closure during subtotal cholecystectomy may reduce rates of bile leak and reoperation. Use of retrieval bag for gallbladder extraction results in minimal benefit. Most studies were underpowered to detect differences in incidence of rare complications.Key operative steps of laparoscopic cholecystectomy should be informed by both compiled data and surgeon preference/patient considerations.

    View details for DOI 10.1016/j.sopen.2022.08.003

    View details for PubMedID 36132940

    View details for PubMedCentralID PMC9483801

  • Challenges in Closing the Gap between Evidence and Practice: International Survey of Institutional Surgical Stabilization of Rib Fractures Guidelines. The journal of trauma and acute care surgery Choi, J., Badrinathan, A., Shine, R., Benz, C., Toia, A., Whitbeck, S., Kryskow, M., White, T., Kirsch, J. 2022


    BACKGROUND: Surgical stabilization of rib fractures (SSRF) has gained increasing interest over the past decade, yet few candidates who could benefit from SSRF undergo operative management. We conducted an international survey of institutional SSRF guidelines comparing congruence between practice and contemporary evidence. We hypothesized that few guidelines reflect comprehensive evidence to facilitate standardized patient selection, operation, and post-operative management.METHODS: A request for institutional rib fracture guidelines was distributed from the Chest Wall Injury Society. SSRF-specific guideline contents were extracted using a priori-designed extraction sheets and compared against 28 SSRF evidence-based recommendations outlined by a panel of 14 international experts. Fisher's exact test compared the proportion of strong and weak evidence-based recommendations specified within a majority of institutional guidelines to evaluate whether strength of evidence is associated with implementation.RESULTS: A total of 36 institutions from three countries submitted institutional rib fracture management guidelines, among which 30 had SSRF-specific guidance. Twenty-eight guidelines (93%) listed at least one injury pattern criteria as an indication for SSRF, while 22 (73%) listed pain and 21 (70%) listed impaired respiratory function as other indications. Quantitative pain and respiratory function impairment thresholds that warrant SSRF varied across institutions. Few guidelines specified non-acute indications for SSRF or perioperative considerations. Seven guidelines (23%) detailed post-operative management but recommended timing and interval for follow-up varied. Overall, only three of the 28 evidence-based SSRF recommendations were specified within a majority of institutional practice guidelines. There was no statistically significant association (p = 0.99) between the strength of recommendation and implementation within institutional guidelines.CONCLUSIONS: Institutional SSRF guidelines do not reflect the totality of evidence available in contemporary literature. Guidelines are especially important for emerging interventions to ensure standardized care delivery and minimize low-value care. Consensus effort is needed to facilitate adoption and dissemination of evidence-based SSRF practices.LEVEL OF EVIDENCE: Level VI, Therapeutic/Care Management.

    View details for DOI 10.1097/TA.0000000000003785

    View details for PubMedID 36149855

  • DeepBackRib: Deep Learning to Understand Factors Associated with Readmissions after Rib Fractures. The journal of trauma and acute care surgery Choi, J., Alawa, J., Tennakoon, L., Forrester, J. D. 2022


    Deep neural networks yield high predictive performance, yet obscure interpretability limits clinical applicability. We aimed to build an explainable deep neural network that elucidates factors associated with readmissions after rib fractures among non-elderly adults, termed DeepBackRib. We hypothesized DeepBackRib could accurately predict readmissions and a game theoretic approach to elucidate how predictions are made would facilitate model explainability.We queried the 2017 National Readmissions Database for index hospitalization encounters of adults aged 18-64 years hospitalized with multiple rib fractures. The primary outcome was 3-month readmission(s). Study cohort was split 60-20-20 into training-validation-test sets. Model input features included demographic/injury/index hospitalization characteristics and index hospitalization International Classification of Diseases, 10th revision diagnosis codes. The seven-layer DeepBackRib comprised multi-pronged strategies to mitigate overfitting and was trained to optimize recall. Shapley Additive Explanation (SHAP) analysis identified the marginal contribution of each input feature for predicting readmissions.20,260 patients met inclusion criteria, among whom 11% (N = 2,185) experienced 3-month readmissions. Feature selection narrowed 3,164 candidate input features to 61, and DeepBackRib yielded 91%, 85%, and 82% recall on the training, validation, and test sets, respectively. SHAP analysis quantified the marginal contribution of each input feature in determining DeepBackRib's predictions: underlying chronic obstructive pulmonary disease and long index hospitalization length-of-stay had positive associations with three-month readmissions, while private primary payer and diagnosis of pneumothorax during index admission had negative associations.We developed and internally validated a high-performing deep learning algorithm that elucidates factors associated with readmissions after rib fractures. Despite promising predictive performance, standalone deep learning algorithms are insufficient for clinical prediction tasks: a concerted effort is needed to ensure clinical prediction algorithms remain explainable.Level III, Prognostic and epidemiological.

    View details for DOI 10.1097/TA.0000000000003791

    View details for PubMedID 36121263

  • Associations of Hearing Loss Severity and Hearing Aid Use With Hospitalization Among Older US Adults. JAMA otolaryngology-- head & neck surgery Thai, A., Khan, S. I., Choi, J., Ma, Y., Megwalu, U. C. 2022


    Hearing loss is associated with higher hospitalization risk among older adults. However, evidence on whether hearing aid use is associated with fewer hospitalizations among individuals with hearing loss remains limited.To assess the association between audiometric hearing loss severity and hearing aid use and hospitalization.This population-based cross-sectional study used audiometric and health care utilization data for respondents aged 65 years or older from 4 cycles of the National Health and Nutrition Examination Survey from 2005 to 2016. Data were analyzed from February 23, 2021, to March 22, 2022.Audiometric hearing loss severity and participant-reported hearing aid use.The main outcome was respondent-reported hospitalization in the past 12 months. Multivariable logistic regression was performed to assess the association of hearing loss severity with hospitalization. To assess the association of hearing aid use with hospitalization, propensity score matching was performed with 2:1 nearest neighbor matching without replacement.Of 2060 respondents (mean [SD] age, 73.9 [5.9] years; 1045 [50.7%] male), 875 (42.5%) had normal hearing, 653 (31.7%) had mild hearing loss, 435 (21.1%) had moderate hearing loss, and 97 (4.7%) had severe to profound hearing loss. On multivariable analysis, moderate and severe hearing loss were associated with hospitalization (moderate hearing loss: odds ratio [OR], 1.50; 95% CI, 1.01-2.24; severe hearing loss: OR, 1.71; 95% CI, 1.03-2.84). Of 1185 respondents with at least mild hearing loss, 200 (16.9%) reported using a hearing aid. Propensity score-matched analysis showed that hearing aid use was not associated with hospitalization (OR, 1.17; 95% CI, 0.74-1.84), including among respondents with moderate or severe hearing loss (OR, 1.17; 95% CI, 0.71-1.92).In this cross-sectional study, hearing loss was associated with higher risk of hospitalization, but hearing aid use was not associated with a reduction in hospitalization risk in the population with hearing loss. The association of hearing aid use with hospitalization should be evaluated in larger prospective studies with reliable data on the frequency of hearing aid use.

    View details for DOI 10.1001/jamaoto.2022.2399

    View details for PubMedID 36048464

  • Building a Trainee-led Research Community to Propel Academic Productivity in Health Services Research. Journal of surgical education Choi, J., Tennakoon, L., Khan, S., Jaramillo, J. D., Rajasingh, C. M., Hakes, N. A., Forrester, J. D., Knowlton, L. M., Nassar, A. K., Weiser, T. G., Spain, D. A. 2022


    Academic productivity is an increasingly important asset for trainees pursuing academic careers. Medical schools and graduate medical education programs offer structured research programs, but providing longitudinal and individualized health services research education remains challenging. Whereas in basic science research, members at multiple training levels support each other within a dedicated community (the laboratory), health services research projects frequently occur within individual faculty-trainee relationships. An optimal match of expertise, availability, and interest may be elusive for an individual mentor-mentee pair. We aimed to share our experience building Surgeons Writing about Trauma (SWAT), a trainee-led research community that propels academic productivity by facilitating peer collaboration and opportunities to transition into independent researchers. We highlight challenges of health services research for trainees, present how structured mentorship and a peer community can address this challenge, and detail SWAT's operational structure to guide replication at peer institutions.

    View details for DOI 10.1016/j.jsurg.2022.02.008

    View details for PubMedID 35272969

  • Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury. European journal of trauma and emergency surgery : official publication of the European Trauma Society Prins, J. T., Van Lieshout, E. M., Ali-Osman, F., Bauman, Z. M., Caragounis, E. C., Choi, J., Christie, D. B., Cole, P. A., DeVoe, W. B., Doben, A. R., Eriksson, E. A., Forrester, J. D., Fraser, D. R., Gontarz, B., Hardman, C., Hyatt, D. G., Kaye, A. J., Ko, H. J., Leasia, K. N., Leon, S., Marasco, S. F., McNickle, A. G., Nowack, T., Ogunleye, T. D., Priya, P., Richman, A. P., Schlanser, V., Semon, G. R., Su, Y. H., Verhofstad, M. H., Whitis, J., Pieracci, F. M., Wijffels, M. M. 2022


    Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients.A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern.In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034).In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

    View details for DOI 10.1007/s00068-022-01906-1

    View details for PubMedID 35192003

  • Contemporary management of obturator hernia. Trauma surgery & acute care open Anderson, T., Bessoff, K. E., Spain, D., Choi, J. 2022; 7 (1): e001011

    View details for DOI 10.1136/tsaco-2022-001011

    View details for PubMedID 36213131

  • Scalable Deep Learning Algorithm to Compute Percent Pulmonary Contusion among Patients with Rib Fractures. The journal of trauma and acute care surgery Choi, J., Mavrommati, K., Li, N. Y., Patil, A., Chan, K., Hindin, D. I., Forrester, J. D. 2022


    Pulmonary contusion exists along a spectrum of severity, yet is commonly binarily classified as present or absent. We aimed to develop a deep learning algorithm to automate percent pulmonary contusion computation and exemplify how transfer learning could facilitate large-scale validation. We hypothesized our deep learning algorithm could automate percent pulmonary contusion computation and that greater percent contusion would be associated with higher odds of adverse inpatient outcomes among patients with rib fractures.We evaluated admission-day chest computed tomography (CT) scans of adults aged ≥18 years admitted to our institution with multiple rib fractures and pulmonary contusions (2010-2020). We adapted a pre-trained convolutional neural network that segments 3-dimensional lung volumes and segmented contused lung parenchyma, pulmonary blood vessels, and computed percent pulmonary contusion. Exploratory analysis evaluated associations between percent pulmonary contusion (quartiles) and odds of mechanical ventilation, mortality, and prolonged hospital length-of-stay using multivariable logistic regression. Sensitivity analysis included pulmonary blood vessel volumes during percent contusion computation.A total of 332 patients met inclusion criteria (median 5 rib fractures), among whom 28% underwent mechanical ventilation and 6% died. The study population's median (IQR) percent pulmonary contusion was 4(2-8)%. Compared to the lowest quartile of percent pulmonary contusion, each increasing quartile was associated with higher adjusted odds of undergoing mechanical ventilation (OR[95%CI]: 1.5[1.1-2.1]) and prolonged hospitalization (OR[95%CI]: 1.6[1.1-2.2]), but not with mortality (OR[95%CI]: 1.1 [0.6-2.0]. Findings were similar on sensitivity analysis.We developed a scalable deep learning algorithm to automate percent pulmonary contusion calculating using chest CTs of adults admitted with rib fractures. Open code sharing and collaborative research is needed to validate our algorithm and exploratory analysis at large scale. Transfer learning can help harness the full potential of big data and high-performing algorithms to bring precision medicine to the bedside.IV.

    View details for DOI 10.1097/TA.0000000000003619

    View details for PubMedID 35319542

  • Outcome-specific Injury Scores (OSIS): Development and Validation of Tailored Prediction Tools for Injured Older Adults Choi, J., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. ELSEVIER SCIENCE INC. 2021: E74
  • Associations of Hearing Loss and Hearing Aid Use with Hospitalization in the Elderly Thai, A., Khan, S. I., Choi, J., Megwalu, U. C. ELSEVIER SCIENCE INC. 2021: S170-S171
  • Traumatic Injury and Death Among Law Enforcement Officers Patil, A., Tennakoon, L., Choi, J., Hakes, N., Spain, D. A., Tung, J. ELSEVIER SCIENCE INC. 2021: E94
  • Scoping review of traumatic hemothorax: Evidence and knowledge gaps, from diagnosis to chest tube removal. Surgery Choi, J., Villarreal, J., Andersen, W., Min, J. G., Touponse, G., Wong, C., Spain, D. A., Forrester, J. D. 2021


    BACKGROUND: Traumatic hemothorax is a common injury that invites diagnostic and management strategy debates. Evidence-based management has been associated with improved care efficiency. However, the literature abounds with long-debated, re-emerging, and new questions. We aimed to consolidate up-to-date evidence on traumatic hemothoraces, focusing on clinical conundra debated in literature.METHODS: We conducted a scoping review of 21 clinical conundra in traumatic hemothorax diagnosis and management according to PRISMA-ScR guidelines. Experimental and observational studies evaluating patients (aged ≥18 years) with traumatic hemothoraces were identified through database searches (PubMed, EMBASE, Web of Science, Cochrane Library; database inception to Sep, 26 2020) and bibliography reviews of selected articles. Three reviewers screened and selected articles using standardized forms.RESULTS: We screened 1,440 articles for eligibility, of which 71 met criteria for synthesis. The review comprises 6 sections: (1) Presumptive antibiotics before tube thoracostomy; (2) Initial diagnostic and intervention decisions; (3) Chest tubes; (4) Retained hemothoraces; (5) Delayed hemothoraces; and (6) Chest tube removal). The 21 conundra across these sections follow the format of a question, our recommendation based on interpretation of available evidence, and succinct rationale. Rationale sections detail knowledge gaps and opportunities for future research.CONCLUSION: Even practices engrained into surgical dogma, such as obtaining chest x-rays after inserting or removing chest tubes and mandating operation for patients who develop chest tube output above a certain threshold, deserve re-evaluation. Some knowledge gaps require rigorous future investigation; sound clinical judgment can likely supplement others.

    View details for DOI 10.1016/j.surg.2021.03.030

    View details for PubMedID 33888318

  • Practical computer vision application to detect hip fractures on pelvic X-rays: a bi-institutional study. Trauma surgery & acute care open Choi, J., Hui, J. Z., Spain, D., Su, Y. S., Cheng, C. T., Liao, C. H. 2021; 6 (1): e000705


    Pelvic X-ray (PXR) is a ubiquitous modality to diagnose hip fractures. However, not all healthcare settings employ round-the-clock radiologists and PXR sensitivity for diagnosing hip fracture may vary depending on digital display. We aimed to validate a computer vision algorithm to detect hip fractures across two institutions' heterogeneous patient populations. We hypothesized a convolutional neural network algorithm can accurately diagnose hip fractures on PXR and a web application can facilitate its bedside adoption.The development cohort comprised 4235 PXRs from Chang Gung Memorial Hospital (CGMH). The validation cohort comprised 500 randomly sampled PXRs from CGMH and Stanford's level I trauma centers. Xception was our convolutional neural network structure. We randomly applied image augmentation methods during training to account for image variations and used gradient-weighted class activation mapping to overlay heatmaps highlighting suspected fracture locations.Our hip fracture detection algorithm's area under the receiver operating characteristic curves were 0.98 and 0.97 for CGMH and Stanford's validation cohorts, respectively. Besides negative predictive value (0.88 Stanford cohort), all performance metrics-sensitivity, specificity, predictive values, accuracy, and F1 score-were above 0.90 for both validation cohorts. Our web application allows users to upload PXR in multiple formats from desktops or mobile phones and displays probability of the image containing a hip fracture with heatmap localization of the suspected fracture location.We refined and validated a high-performing computer vision algorithm to detect hip fractures on PXR. A web application facilitates algorithm use at the bedside, but the benefit of using our algorithm to supplement decision-making is likely institution dependent. Further study is required to confirm clinical validity and assess clinical utility of our algorithm.III, Diagnostic tests or criteria.

    View details for DOI 10.1136/tsaco-2021-000705

    View details for PubMedID 33912689

    View details for PubMedCentralID PMC8031685

  • The impact of trauma systems on patient outcomes. Current problems in surgery Choi, J., Carlos, G., Nassar, A. K., Knowlton, L. M., Spain, D. A. 2021; 58 (1): 100840

    View details for DOI 10.1016/j.cpsurg.2020.100840

    View details for PubMedID 33431135

  • Evidence-based surgery for laparoscopic appendectomy: A stepwise systematic review. Surgery open science Bessoff, K. E., Choi, J., Wolff, C. J., Kashikar, A., Carlos, G. M., Caddell, L., Khan, R. I., Stave, C. D., Spain, D. A., Forrester, J. D. 2021; 6: 29-39


    Appendectomy is a common emergency surgery performed globally. Despite the frequency of laparoscopic appendectomy, consensus does not exist on the best way to perform each procedural step. We identified literature on key intraoperative steps to inform best technical practice during laparoscopic appendectomy.Research questions were framed using the population, indication, comparison, outcome (PICO) format for 6 key operative steps of laparoscopic appendectomy: abdominal entry, placement of laparoscopic ports, division of mesoappendix, division of appendix, removal of appendix, and fascial closure. These questions were used to build literature queries in PubMed, EMBASE, and the Cochrane Library databases. Evidence quality and certainty was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) definitions.Recommendations were rendered for 6 PICO questions based on 28 full length articles. Low quality evidence favors direct trocar insertion for abdominal entry and establishment of pneumoperitoneum. Single port appendectomy results in improved cosmesis with unclear clinical implications. There was insufficient data to determine the optimal method of appendiceal stump closure, but use of a specimen extraction bag reduces rates of superficial surgical site infection and intra-abdominal abscess. Port sites made with radially dilating trocars are less likely to necessitate closure and are less likely to result in port site hernia. When port sites are closed, a closure device should be used.Key operative steps of laparoscopic appendectomy have sufficient data to encourage standardized practice.

    View details for DOI 10.1016/j.sopen.2021.08.001

    View details for PubMedID 34604728

    View details for PubMedCentralID PMC8473533

  • Intercostal Nerve Cryoablation during Surgical Stabilization of Rib Fractures. The journal of trauma and acute care surgery Choi, J., Min, J. G., Jopling, J. K., Meshkin, S., Bessoff, K. E., Forrester, J. D. 2021


    Intercostal nerve cryoablation (IC) offers potential for targeted and durable analgesia for patients with traumatic rib fractures. Our pilot study aimed to investigate thoracoscopic IC's safety, feasibility, and preliminary efficacy for patients undergoing surgical stabilization of rib fractures (SSRF). We hypothesized concurrent SSRF-IC is a safe and feasible procedure without immediate or long-term complications.We retrospectively evaluated patients aged ≥18 years who underwent SSRF (with or without IC) for acute rib fractures at our Level I trauma center between 1 September 2019 and 30 September 2020. We performed IC under thoracoscopic visualization (-70 °C for 2 minutes per intercostal nerve bundle). Among patients whose only operative procedure during hospitalization was SSRF, we evaluated post-SSRF length of stay, operative times, opioid requirements (oral morphine equivalents) and pain scores (Numerical Rating Scale). Generalized estimating equations compared SSRF and SSRF-IC group outcomes (population mean[robust standard error]). We assessed long-term outcomes of patients who underwent SSRF-IC.Thirty-four patients (144 ribs) underwent SSRF; of these, 20 patients (135 ribs) underwent SSRF-IC. Patients who did and did not undergo concurrent IC had no significant difference demographic, injury, or hospitalization characteristics. Among 20 patients who did not undergo other operations, 12 underwent SSRF-IC. We did not find significant difference between SSRF and SSRF-IC groups' median operative times or post-SSRF length of stay. Compared to SSRF group, SSRF-IC group did not have statistically significant change in pain score (0.2[1.5] lower) or opioid use (43.9[86.1] mg/day greater) between 12-hours before SSRF and last 24 admission hours. Among 17 SSRF-IC patients who followed-up post-discharge (median[range]: 160[9-357] days), one reported mild chest wall paresthesia; no other complications were reported.Pilot study performing 135 intercostal nerve cryoablations on 20 patients suggests IC is safe and feasible for patients undergoing SSRF. Evaluating IC's analgesic efficacy for rib fractures requires further study.Level IV, prognostic and epidemiological study.

    View details for DOI 10.1097/TA.0000000000003391

    View details for PubMedID 34446656

  • Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: a systematic review Trauma Surgery & Acute Care Open Cha, P. I., Min, J. G., Patil, A., Choi, J., Kothary, N. N., Forrester, J. D. 2021: e000690
  • Systematic Review and Meta-Analysis of Hardware Failure in Surgical Stabilization of Rib Fractures: Who, What, When, Where, and Why? The Journal of surgical research Choi, J., Kaghazchi, A., Sun, B., Woodward, A., Forrester, J. D. 2021; 268: 190-198


    Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws of hardware failure -who, what, when, where, and why- remains unclear. We aimed to synthesize available evidence on the five Ws and outline future research agenda for mitigating hardware failure.Experimental and observational studies published between 2009 and 2020 evaluating adults undergoing SSRF for traumatic rib fractures underwent evidence synthesis. We performed random effects meta-analysis of cohort/consecutive case studies. We calculated pooled prevalence of SSRF hardware failures using Freeman-Tukey double arcsine transformation and assessed study heterogeneity using DerSimonian-Laird estimation. We performed meta-regression with rib fracture acuity (acute or chronic) and hardware type (metal plate or not metal plate) as moderators.Twenty-nine studies underwent qualitative synthesis and 24 studies (2404 SSRF patients) underwent quantitative synthesis. Pooled prevalence of hardware failure was 4(3-7)%. Meta-regression showed fracture acuity was a significant moderator (P = 0.002) of hardware failure but hardware type was not (P = 0.23). Approximately 60% of patients underwent hardware removal after hardware failure. Mechanical failures were the most common type of hardware failure, followed by hardware infections, pain/discomfort, and non-union. Timing of hardware failure after surgery was highly variable, but 87% of failures occurred after initial hospitalization. Mechanical failures was attributed to technical shortcomings (i.e. short plate length) or excessive force on the thoracic cavity.SSRF hardware failure is an uncommon complication. Not all hardware failures are consequential, but insufficient individual patient data precluded characterizing where and why hardware failures occur. Minimizing SSRF hardware failure requires concerted research agenda to expand on the paucity of existing evidence.

    View details for DOI 10.1016/j.jss.2021.06.054

    View details for PubMedID 34333416

  • Complication to consider: delayed traumatic hemothorax in older adults Trauma Surgery Acute Care Open Choi, J., Anand, A., Sborov, K. D., Walton, W., Chow, L., Guillamondegui, O., Dennis, B. M., Spain, D., Staudenmayer, K. 2021
  • Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers. American journal of surgery Choi, J. n., Kaghazchi, A. n., Dickerson, K. L., Tennakoon, L. n., Spain, D. A., Forrester, J. D. 2021


    We aimed to elucidate management patterns and outcomes of high-risk patients with rib fractures (elderly or flail chest) across non-trauma and trauma centers. We hypothesized highest-capacity (level I) centers would have best outcomes for high-risk patients.We queried the 2016 National Emergency Department Sample to identify adults presenting with rib fractures. Multivariable regression assessed ED and inpatient events across non-trauma and level III/II/I trauma centers.Among 504,085 rib fracture encounters, 46% presented to non-trauma centers. Elderly patients with multiple rib fractures had stepwise increase in inpatient admission odds and stepwise decrease in pneumonia odds at higher-capacity trauma centers compared to non-trauma centers. Among patients with flail chest, odds of undergoing surgical stabilization (SSRF) increased at trauma centers. Undergoing SSRF was associated with reduced mortality but remained underutilized.Half of patients with rib fractures present to non-trauma centers. Nationwide care-optimization for high-risk patients requires further effort.

    View details for DOI 10.1016/j.amjsurg.2021.02.013

    View details for PubMedID 33612257

  • Concomitant Sternal Fractures: Harbinger of Worse Pulmonary Complications and Mortality in Patients With Rib Fractures. The American surgeon Choi, J. n., Mulaney, B. n., Sun, B. n., Trimble, R. n., Tennakoon, L. n., Spain, D. A., Forrester, J. D. 2021: 3134821991978


    Sternal and rib fractures are common concomitant injuries. However, the impact of concurrent sternal fractures on clinical outcomes of patients with rib fractures is unclear. We aimed to unveil the pulmonary morbidity and mortality impact of concomitant sternal fractures among patients with rib fractures.We identified adult patients admitted with traumatic rib fractures with vs. without concomitant sternal fractures using the 2012-2014 National Inpatient Sample (NIS). After 2:1 propensity score matching and adjustment for residual imbalances, we compared risk of pulmonary morbidity and mortality between patients with vs. without concomitant sternal fractures. Subgroup analysis in patients with flail chest assessed whether sternal fractures modify the association between undergoing surgical stabilization of rib fractures (SSRF) and pulmonary morbidity or mortality.Of 475 710 encounters of adults admitted with rib fractures, 24 594 (5%) had concomitant sternal fractures. After 2:1 propensity score matching, patients with concomitant sternal fractures had 70% higher risk (95% CI: 50-90% higher, P < 0.001) of undergoing tracheostomy, 40% higher risk (30-50% higher, P <.001) of undergoing intubation, and 20% higher risk of respiratory failure (10-30% higher, P <.001) and mortality (10-40% higher, P =.007). Subgroup analysis of 8600 patients with flail chest showed concomitant sternal fractures did not impact the association between undergoing SSRF and any pulmonary morbidity or mortality.Concomitant sternal fractures are associated with increased risk for pulmonary morbidity and mortality among patients with rib fractures. However, our findings are limited by a binary definition of sternal fractures, which encompasses heterogeneous injury patterns with likely variable clinical relevance.

    View details for DOI 10.1177/0003134821991978

    View details for PubMedID 33522281

  • Early National Landscape of Surgical Stabilization of Sternal Fractures. World journal of surgery Choi, J. n., Khan, S. n., Syed, M. n., Tennakoon, L. n., Forrester, J. D. 2021


    Operative management of chest wall injuries aims to restore respiratory mechanics and mitigate pulmonary complications. Extensive studies support surgical stabilization of rib fractures (SSRF) for select patients, but role for surgical stabilization of sternal fractures (SSSF) remains unclear. We aimed to understand national prevalence of SSSF and compare outcomes after surgical stabilization and non-operative management of sternal fractures.We retrospectively analyzed adult patients (age ≥ 18 years) admitted with sternal fractures after blunt trauma using the 2016 National Trauma Data Bank. We compared odds of inpatient mortality, pneumonia, and respiratory failure for propensity score matched patients (4:1) who underwent non-operative management vs SSSF. We characterized subgroup of patients with concurrent rib and sternal fractures who underwent concomitant SSRF-SSSF.We identified 14,760 encounters of adults admitted with sternal fractures; 270 (1.8%) underwent SSSF. Compared to matched patients who underwent non-operative management, patients who underwent SSSF had lower odds of mortality (OR [95%CI]: 0.19 [0.06-0.62], p = 0.006). Adjusted for trauma center level, Mantel-Haenszel mortality odds remained lower for patients who underwent SSSF. Odds of pneumonia and respiratory failure were similar between matched groups. Among 46% of patients who had concomitant rib fractures, 0.3% (n = 18) underwent concurrent SSRF-SSSF and these patients survived hospitalization without pneumonia or respiratory failure.A vast majority of patients who suffer sternal fractures undergo non-operative management. Potential mortality benefit of SSSF and concurrent SSRF-SSSF's role for commonly concomitant rib and sternal fractures deserve further study. Our preliminary findings call for delineating heterogeneity of sternal fractures and establishing consensus SSSF indications.

    View details for DOI 10.1007/s00268-021-06007-5

    View details for PubMedID 33604709

  • Incidence and Management of Arterial Vascular Trauma in the US Kashikar, A., Choi, J., Tennakoon, L., Spain, D., Arya, S. ELSEVIER SCIENCE INC. 2020: E263–E264
  • Common, Severe, and Preventable: Agricultural Machinery Trauma in the US Hakes, N. A., Jaramillo, J. D., Choi, J., Spain, D. A., Tennakoon, L., Forrester, J. D. ELSEVIER SCIENCE INC. 2020: E231
  • Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI). The journal of trauma and acute care surgery Prins, J. T., Van Lieshout, E. M., Ali-Osman, F. n., Bauman, Z. M., Caragounis, E. C., Choi, J. n., Benjamin Christie, D. n., Cole, P. A., DeVoe, W. B., Doben, A. R., Eriksson, E. A., Forrester, J. D., Fraser, D. R., Gontarz, B. n., Hardman, C. n., Hyatt, D. G., Kaye, A. J., Ko, H. J., Leasia, K. N., Leon, S. n., Marasco, S. F., McNickle, A. G., Nowack, T. n., Ogunleye, T. D., Priya, P. n., Richman, A. P., Schlanser, V. n., Semon, G. R., Su, Y. H., Verhofstad, M. H., Whitis, J. n., Pieracci, F. M., Wijffels, M. M. 2020


    Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared to nonoperative management, is associated with favorable outcomes in patients with TBI.A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were Intensive Care Unit (ICU-LOS) and hospital length of stay (HLOS), tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS 9-12) and severe (GCS ≤8) TBI.The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. SSRF was performed at a median of 3 days and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (OR 0.59 (95% CI 0.38-0.98), p=0.043) and 30-day mortality (OR 0.32 (95% CI 0.11-0.91), p=0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (0.19 (95% CI 0.04-0.88), p=0.034).In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI.Therapeutic, level IV.

    View details for DOI 10.1097/TA.0000000000002994

    View details for PubMedID 33093293

  • Necessity of routine chest radiograph in blunt trauma resuscitation: time to evaluate dogma with evidence. The journal of trauma and acute care surgery Choi, J. n., Forrester, J. D., Spain, D. A. 2020

    View details for DOI 10.1097/TA.0000000000002793

    View details for PubMedID 32467468

  • Pulmonary contusions in patients with rib fractures: The need to better classify a common injury. American journal of surgery Choi, J. n., Tennakoon, L. n., You, J. G., Kaghazchi, A. n., Forrester, J. D., Spain, D. A. 2020


    Pulmonary contusions are common injuries. Computed tomography reveals vast contused lung volume spectrum, yet pulmonary contusions are defined dichotomously (unilateral vs bilateral). We assessed whether there is stepwise increased risk of pulmonary complications among patients without, with unilateral, and with bilateral pulmonary contusion.We identified adults admitted with rib fractures using the largest US inpatient database. After propensity-score-matching patients without vs with unilateral vs bilateral pulmonary contusions and adjusting for residual confounders, we compared risk for pneumonia, ventilator-associated pneumonia (VAP), respiratory failure, intubation, and mortality.Among 148,140 encounters of adults with multiple rib fractures, 19% had concomitant pulmonary contusions. Matched patients with pulmonary contusions had increased risk of pneumonia 19% [95%CI:16-33%], respiratory failure 40% [95%CI: 31-50%], and intubation 46% [95%CI: 33-61%]. Delineation showed bilateral contusions, not unilateral contusions, attributed to increased risk of complications.There is likely a correlation between contused lung volume and risk of pulmonary complications; dichotomously classifying pulmonary contusions is insufficient. Better understanding this correlation requires establishing the clinically significant contusion volume and a correspondingly refined classification system.

    View details for DOI 10.1016/j.amjsurg.2020.07.022

    View details for PubMedID 32854902

  • Surgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures. Surgical infections Forrester, J. D., Wolff, C. J., Choi, J. n., Colling, K. P., Huston, J. M. 2020


    Background: Facial fractures are common in traumatic injury. Antibiotic administration practices for traumatic facial fractures differ widely. Methods: The Surgical Infection Society's (SIS's) Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic administration in the management of traumatic facial fractures. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Pre-operative antibiotics were defined as those administered more than 1 hour before surgery. Peri-operative antibiotics were those administered within 1 hour of the start of surgery depending on the type of antibiotic and as late as ≤24 hours after surgery. Post-operative antibiotics were defined as those administered >24 hours after surgery. Prophylactic antibiotics were those administered for >24 hours without a documented infection. Evaluation of the published evidence was performed with the GRADE system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that in adult patients with non-operative upper face, midface, or mandibular fractures, prophylactic antibiotics not be prescribed and that in adult patients with operative, non-mandibular fractures, pre-operative antibiotics likewise not be prescribed. We recommend that in adult patients with operative, mandibular fractures, pre-operative antibiotics not be prescribed; and in adult patients with operative, non-mandibular facial fractures, post-operative (>24 hours) antibiotics again not be prescribed. We recommend that in adult patients with operative, mandibular facial fractures, post-operative antibiotics (> 24 hours) not be prescribed. Conclusions: This guideline summarizes the current SIS recommendations regarding antibiotic management of patients with traumatic facial fractures.

    View details for DOI 10.1089/sur.2020.107

    View details for PubMedID 32598227

  • Creation and implementation of a novel clinical workflow based on the AAST uniform anatomic severity grading system for emergency general surgery conditions. Trauma surgery & acute care open Bessoff, K. E., Choi, J. n., Bereknyei Merrell, S. n., Nassar, A. K., Spain, D. n., Knowlton, L. M. 2020; 5 (1): e000552


    Emergency general surgery (EGS) conditions encompass a variety of diseases treated by acute care surgeons. The heterogeneity of these diseases limits infrastructure to facilitate EGS-specific quality improvement (QI) and research. A uniform anatomic severity grading system for EGS conditions was recently developed to fill this need. We integrated this system into our clinical workflow and examined its impact on research, surgical training, communication, and patient care.The grading system was integrated into our clinical workflow in a phased fashion through formal education and a written handbook. A documentation template was also deployed in our electronic medical record to prospectively assign severity scores at the time of patient evaluation. Mixed methods including a quantitative survey and qualitative interviews of trainees and attending surgeons were used to evaluate the impact of the new workflow and to identify obstacles to its adoption.We identified 2291 patients presenting with EGS conditions during our study period. The most common diagnoses were small bowel obstruction (n=470, 20.5%), acute cholecystitis (n=384, 16.8%), and appendicitis (n=370, 16.1%). A total of 21 qualitative interviews were conducted. Twenty interviewees (95.2%) had a positive impression of the clinical workflow, citing enhanced patient care and research opportunities. Fifteen interviewees (75.0%) reported the severity grading system was a useful framework for clinical management, with five participants (25.0%) indicating the system was useful to facilitate clinical communication. Participants identified solutions to overcome barriers to adoption of the clinical workflow.The uniform anatomic severity grading system can be readily integrated into a clinical workflow to facilitate prospective data collection for QI and research. The system is perceived as valuable by users. Educational initiatives that focus on increasing familiarity with the system and its benefits will likely improve adoption of the classification system and the clinical workflow that uses it.Level III.

    View details for DOI 10.1136/tsaco-2020-000552

    View details for PubMedID 32953998

    View details for PubMedCentralID PMC7481073

  • Prospectively Assigned AAST Grade versus Modified Hinchey Class and Acute Diverticulitis Outcomes. The Journal of surgical research Choi, J. n., Bessoff, K. n., Bromley-Dulfano, R. n., Li, Z. n., Gupta, A. n., Taylor, K. n., Wadhwa, H. n., Seltzer, R. n., Spain, D. A., Knowlton, L. M. 2020


    The American Association for the Surgery of Trauma (AAST) recently developed a classification system to standardize outcomes analyses for several emergency general surgery conditions. To highlight this system's full potential, we conducted a study integrating prospective AAST grade assignment within the electronic medical record.Our institution integrated AAST grade assignment into our clinical workflow in July 2018. Patients with acute diverticulitis were prospectively assigned AAST grades and modified Hinchey classes at the time of surgical consultation. Support vector machine-a machine learning algorithm attuned for small sample sizes-was used to compare the associations between the two classification systems and decision to operate and incidence of complications.67 patients were included (median age of 62 y, 40% male) for analysis. The decision for operative management, hospital length of stay, intensive care unit admission, and intensive care unit length of stay were associated with both increasing AAST grade and increasing modified Hinchey class (all P < 0.001). AAST grade additionally showed a correlation with complication severity (P = 0.02). Compared with modified Hinchey class, AAST grade better predicted decision to operate (88.2% versus 82.4%).This study showed the feasibility of electronic medical record integration to support the full potential of AAST classification system's utility as a clinical decision-making tool. Prospectively assigned AAST grade may be an accurate and pragmatic method to find associations with outcomes, yet validation requires further study.

    View details for DOI 10.1016/j.jss.2020.10.016

    View details for PubMedID 33248670

  • A Novel Approach to Deliver Therapeutic Extracellular Vesicles Directly into the Mouse Kidney Cells Ullah, M., Liu, D. D., Rai, S., Razavi, M., Choi, J., Wang, J., Concepcion, W., Thakor, A. S. 2020; 9 (4): 937

    View details for DOI 10.3390/cells9040937

  • Concurrent large bowel obstruction secondary to idiopathic mesenteroaxial gastric volvulus. Trauma surgery & acute care open Anand, A., Choi, J., Jaramillo, J. D., Lau, J. 2020; 5 (1): e000582

    View details for DOI 10.1136/tsaco-2020-000582

    View details for PubMedID 33024829

  • The impact of trauma systems on patient outcomes Current Problems in Surgery Choi, J., Carlos, G., Nassar, A. K., Knowlton, L. M., Spain, D. A. 2020
  • Lessons from Epidemics, Pandemics, and Surgery. Journal of the American College of Surgeons Hakes, N. A., Choi, J. n., Spain, D. A., Forrester, J. D. 2020

    View details for DOI 10.1016/j.jamcollsurg.2020.08.736

    View details for PubMedID 32828842

  • National readmission rates after surgical stabilization of traumatic rib fractures The Journal of Cardiothoracic Trauma Cha, P. I., Hakes, N. A., Choi, J., Tennakoon, L., Spain, D. A., Forrester, J. D. 2020; 5 (1): 16-21

    View details for DOI 10.4103/jctt.jctt_6_20

  • Intravenous lidocaine as a non-opioid adjunct analgesic for traumatic rib fractures. PloS one Choi, J. n., Zamary, K. n., Barreto, N. B., Tennakoon, L. n., Davis, K. M., Trickey, A. W., Spain, D. A. 2020; 15 (9): e0239896


    Pain management is the pillar of caring for patients with traumatic rib fractures. Intravenous lidocaine (IVL) is a well-established non-opioid analgesic for post-operative pain, yet its efficacy has yet to be investigated in trauma patients. We hypothesized that IVL is associated with decreased inpatient opioid requirements among patients with rib fractures.We retrospectively evaluated adult patients presenting to our Level 1 trauma center with isolated chest wall injuries. After 1:1 propensity score matching patients who received vs did not receive IVL, we compared the two groups' average daily opioid use, opioid use in the last 24 hours of admission, and pain scores during admissions hours 24-48. We performed multivariable linear regression for these outcomes (with sensitivity analysis for the opioid use outcomes), adjusting for age as a moderating factor and controlling for hospital length of stay and injury severity.We identified 534 patients, among whom 226 received IVL. Those who received IVL were older and had more serious injury. Compared to propensity-score matched patients who did not receive IVL, patients who received IVL had similar average daily opioid use and pain scores, but 40% lower opioid use during the last 24 hours of admission (p = 0.002). Multivariable regression-with and without sensitivity analysis-did not show an effect of IVL on any outcomes.IVL was crudely associated with decreased opioid requirements in the last 24 hours of admission, the time period associated with opioid use at 90 days post-discharge. However, we did not observe beneficial effects of IVL on multivariable adjusted analyses; we are conducting a randomized control trial to further evaluate IVL's opioid-sparing effects for patients with rib fractures.

    View details for DOI 10.1371/journal.pone.0239896

    View details for PubMedID 32986770

  • Evidenced-Based Practice Among Trainees: A Survey on Facial Trauma Wound Management. Journal of surgical education Choi, J. n., Traboulsi, A. A., Okland, T. S., Sadauskas, V. n., Perrault, D. n., Spain, D. A., Lorenz, H. P., Weiser, T. G. 2020


    Assess whether facial trauma wound care and antibiotic use recommendations are guided by evidence-based practice (EBP) or practice patterns, and investigate strategies to improve EBP adoption among surgical trainees.We conducted a survey of all trainees who manage facial trauma (general surgery, emergency medicine, plastic surgery, otolaryngology) to assess clinical knowledge and sources of treatment recommendations. Clinical questions were based on Oxford Center for Evidence-Based Medicine Level 1 or 2 evidence. We measured internal validity of questions using Cronbach's α. Results were weight-adjusted for nonresponse and then analyzed using Welch t test and descriptive statistics.Stanford Hospital and Clinics, a Level I trauma center.Response rate was 50.3% overall (78/155). For recommendations on facial trauma wound and antibiotic use, nonspecialty junior residents most frequently relied on their own senior or specialty residents (79.1%); nonspecialty senior residents relied on specialty residents (67.9%). Specialty junior residents most often relied on their own senior residents (51.0%), the majority of whom made recommendations based on their own knowledge (73.2%). Questions assessing EBP knowledge had Cronbach's α of 0.98; response accuracy was similar between specialty and nonspecialty residents (54.6% vs 55.5%, p = 0.96). When provided recommendations that conflict with EBP, both nonspecialty and specialty residents more frequently followed recommendations rather than EBP; junior residents reported doing so to avoid conflict with superiors. Total 92.6% of surveyed residents felt cross-departmental EBP guidelines would improve patient care.Facial trauma wound care and antibiotic recommendations disseminate down seniority and from craniofacial specialty to nonspecialty residents, yet knowledge of EBP among senior specialty and nonspecialty residents was weak. EBP may be difficult to adopt in the absence of consensus society guidelines. To address this gap, we published a review of EBP for facial trauma and plan to update our trauma manual with cross-departmental guidelines to facilitate EBP adoption among trainees.

    View details for DOI 10.1016/j.jsurg.2020.03.015

    View details for PubMedID 32461098

  • Review of Facial Trauma Management. The journal of trauma and acute care surgery Choi, J. n., Lorenz, H. P., Spain, D. A. 2020


    Facial trauma afflicts significant morbidity and mortality with potential to compromise critical adjacent structures. Facial trauma management is often entrusted to the hands of the craniofacial surgeon; evidence-based practice may be difficult to distinguish from outdated practice for the non-craniofacial trauma surgeon. We review up-to-date evidence in facial trauma management relevant for trauma surgeons, and highlight areas needing further research.Review.

    View details for DOI 10.1097/TA.0000000000002589

    View details for PubMedID 31972757

  • Altered Mental Status and Hypercalcemia with a Splenic Mass. The journal of trauma and acute care surgery Khan, S., Choi, J., Patel, S. A., Spain, D. A. 2019

    View details for DOI 10.1097/TA.0000000000002534

    View details for PubMedID 31688787

  • Atraumatic acute forearm compartment syndrome due to systemic heparin. Trauma surgery & acute care open Chavez, G. n., Choi, J. n., Fogel, N. n., Jaramillo, J. D., Murphy, M. n., Spain, D. n. 2019; 4 (1): e000399

    View details for DOI 10.1136/tsaco-2019-000399

    View details for PubMedID 31799418

    View details for PubMedCentralID PMC6861105

  • Meckel's Diverticulum Fistulization: Another Complication to Consider. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Choi, J. n., Hawn, M. n. 2019

    View details for DOI 10.1007/s11605-019-04378-8

    View details for PubMedID 31468335

  • LAPRA-TY for laparoscopic repair of traumatic diaphragmatic hernia without intracorporeal knot tying. Trauma surgery & acute care open Choi, J. n., Pan, J. n., Forrester, J. D., Spain, D. n., Browder, T. D. 2019; 4 (1): e000334


    A 38-year-old man was brought in by ambulance as a trauma activation after sustaining a self-inflicted stab wound in the left upper quadrant with a kitchen knife. His primary survey was unremarkable and his vital signs were normal. Secondary survey revealed a 2 cm transverse stab wound inferior and medial to the left nipple. Extended focused assessment with sonography for trauma (FAST) did not show intra-abdominal or pericardial fluid and chest X-ray did not show a definite pneumothorax or hemothorax.Wound exploration at bedside.Admit for observation and serial examinations.Exploratory laparotomy and open repair of traumatic diaphragmatic injury (TDI).Thoracotomy and open repair of TDI.Diagnostic laparoscopy and laparoscopic repair of TDI.

    View details for DOI 10.1136/tsaco-2019-000334

    View details for PubMedID 31321313

    View details for PubMedCentralID PMC6606065

  • Perianal Extramammary Paget's Disease: More Than Meets the Eye. Digestive diseases and sciences Choi, J. n., Zemek, A. n., Lee, G. K., Kin, C. n. 2018

    View details for PubMedID 29696480

  • A Novel Approach for Therapeutic Delivery to the Rodent Pancreas Via Its Arterial Blood Supply. Pancreas Choi, J. n., Wang, J. n., Ren, G. n., Thakor, A. S. 2018; 47 (7): 910–15


    Endovascular techniques can now access the arterial blood supply of the pancreas in humans to enable therapeutics to reach the gland in high concentrations while concurrently avoiding issues related to non-targeted delivery. However, there is no way to replicate this in small animals. In a rat model, we therefore developed a novel non-terminal technique to deliver therapeutics to different regions of the pancreas, via its arterial blood supply.In female Wistar rats, selective branches of the celiac artery were temporarily ligated, depending on the region of the pancreas being targeted. Trypan blue dye was then administered as a surrogate marker for a therapeutic agent, via the celiac artery, and its staining/distribution throughout the pancreas determined. Postoperatively, animals were monitored daily, and serum was evaluated for markers of pancreatitis, liver, and metabolic function.Using this technique, we could selectively target the head, body/tail, or entire gland of the pancreas, via its arterial blood supply, with minimal nontarget staining. Following the procedure, all animals recovered with no evidence of pancreatitis or liver/metabolic dysfunction.Our study demonstrates a novel technique that can be used to selectively deliver therapeutics directly to the rat pancreas in a safe manner with full recovery of the animal.

    View details for PubMedID 29975350

  • Systems approach to uncover signaling networks in primary immunodeficiency diseases. journal of allergy and clinical immunology Choi, J., Fernandez, R., Maecker, H. T., Butte, M. J. 2017

    View details for DOI 10.1016/j.jaci.2017.03.025

    View details for PubMedID 28412396