Testosterone, cortisol, and psychopathy: Further evidence with the Levenson self-report psychopathy scale and the inventory of callous unemotional traits.

The current study explored associations between testosterone, cortisol, and both the Levenson Self-Report Psychopathy Scale (LSRPS) and the Inventory of Callous Unemotional (ICU) traits. Data were gathered from a relatively large sample of university students (n = 522) and analyses considered direct and interactive associations between hormones and psychopathic traits, as well as interactions between these associations and the time of day at which samples were gathered and the sex of participants. Baseline cortisol had a negative association with LSRPS primary psychopathy scores. In addition, baseline cortisol interacted with the time of day in association with LSRPS total scores. Simple slopes analyses indicated cortisol had a negative association with LSRPS total scores in the morning but not the afternoon. Interactions among hormone measures were not statistically significant. There was also no evidence for the moderation of associations between hormones and psychopathic traits by sex.

Impact of Concomitant Traumatic Pancreatic and Colon Injuries on Outcomes.

BACKGROUND: Colon and pancreatic injuries have both long been independently associated with intraabdominal infectious complications in trauma patients. The goal of this study was to evaluate the impact of concomitant pancreatic injury on outcomes in patients with traumatic colon injuries. METHODS: Consecutive patients over a 3-year period who underwent operative management of colon injuries were identified. Patient characteristics, severity of injury and shock, presence and grade of pancreatic injury, and intraoperative packed red blood cell (PRBC) transfusions were recorded. Outcomes including intraabdominal abscess formation and suture line failure were collected and compared. Multivariable logistic regression analysis was then performed to determine the impact of concomitant pancreatic injury on intraabdominal abscess formation. RESULTS: 243 patients with traumatic colon injuries were identified. 17 of these also had pancreatic injuries. Patients with combined colon and pancreatic injuries were clinically similar to those with isolated colon injuries with respect to age, gender, penetrating mechanism of injury, admission lactate, ISS, suture line failure, and admission systolic blood pressure. Both intraabdominal abscess rates (88.2% vs 29.6%, P < .001) and intraoperative PRBC transfusions (8 vs 1 units, P = .004) were higher in the combined pancreatic and colon injury group. Multivariable logistic regression identified both intraoperative PRBC transfusions (odds ratio, 1.09; 95% confidence interval, 1.04-1.15; P < .001) and concomitant pancreatic injury (odds ratio, 14.8; 95% confidence interval, 3.92-96.87; P < .001) as independent predictors of intraabdominal abscess formation. DISCUSSION: Both intraoperative PRBC transfusions and presence of concomitant pancreatic injury are independent predictors of intraabdominal abscess formation in patients with traumatic colon injuries.

The association between the 2D:4D ratio and psychopathic characteristics.

Prior research has identified relations between prenatal testosterone exposure and various antisocial and criminal behaviors. However, less is known about the association between prenatal testosterone exposure and personality traits, such as psychopathy. This study used self-report and biometric data from a sample of undergraduates (n = 491) at a large southwestern university to examine the association between prenatal testosterone exposure (measured by the 2D:4D ratio) and three dimensions of psychopathy (i.e., callousness, egocentricity, and antisocial behavior). Analyses were stratified by sex to explore sex-specific biological underpinnings of psychopathy in young adulthood. Results showed that males scored significantly higher in psychopathic traits and reported significantly lower 2D:4D ratios, compared to females. Additionally, 2D:4D ratios were negatively associated with egocentricity in males, but not females. These findings contribute to a growing literature on the organizational effects that prenatal testosterone exposure may have on the development of different dimensions of psychopathy.

Testosterone, cortisol, and criminal behavior in men and women.

Only two studies to date have considered the joint effects of testosterone and cortisol on direct measures of criminal behavior. The current study extends this earlier work by incorporating the direct and interactive effects of baseline hormone measures and hormone change scores in response to social stress. The current study also extends prior work by considering distinct measures of different criminal behavior types and sex differences. Analyses based on a large sample of undergraduates indicated that testosterone had a positive and statistically significant association with impulsive and violent criminal behavior. The interaction of testosterone with cortisol had a negative association with income generating crime. Simple slopes analyses of this interaction indicated testosterone had a positive association with income generating crime when cortisol was low (-1 SD). Associations between hormones and criminal behavior were not moderated by sex.

Optimal time to thoracoscopy for trauma patients with retained hemothorax.

BACKGROUND: Retained hemothorax remains a common problem after thoracic trauma with associated morbidity and prolonged hospitalizations. The goal of this study was to examine the impact of time to video assisted thoracoscopic surgery (VATS) on pulmonary morbidity using a large, national data set. METHODS: Patients undergoing VATS for retained hemothorax within the first 14 days postinjury were identified from the Trauma Quality Improvement Program database over 5 years, ending in 2016. Demographics, mechanism, severity of injury, severity of shock, time to VATS, pulmonary morbidity, and mortality were recorded. Multivariable logistic regression analysis was performed to determine independent predictors of pulmonary morbidity. Youden's index was then used to identify the optimal time to VATS. RESULTS: From the Trauma Quality Improvement Program database, 3,546 patients were identified. Of these, 2,355 (66%) suffered blunt injury. The majority were male (81%) with a median age and Injury Severity Score of 46 and 16, respectively. The median time to VATS was 134 hours. Both pulmonary morbidity (13 vs 17%, P = .004) and hospital length of stay (9 vs 12 days, P < .0001) were significantly reduced in patients undergoing VATS before 3.9 days. Multivariable logistic regression identified VATS during the first 7 days as the only modifiable risk factor significantly associated with reduced pulmonary morbidity (odds ratio 0.52; 95% confidence interval 0.43-0.63, P < .0001). CONCLUSION: Patients undergoing VATS for retained hemothorax have significant morbidity and prolonged length of stay. VATS within the first week of admission results in fewer pulmonary complications and shorter length of stay. In fact, the optimal time to VATS was identified as 3.9 days and was the only modifiable risk factor associated with decreased pulmonary morbidity.

The sustained effect of a temporary measure: Urban firearm mortality following expiration of the Federal Assault Weapons Ban.

BACKGROUND: The Federal Assault Weapons Ban (FAWB) was in effect from 1994 to 2004. We sought to examine its impact on firearm-related homicides. METHODS: All firearm-related homicides occurring in three metropolitan United States cities were analyzed during the decade preceding (PRE), during (BAN), and after (POST) the FAWB. Files were obtained from the Federal Bureau of Investigation. Rates of firearm-related homicides were stratified by year and compared using simple linear regression. RESULTS: 21,327 firearm-related homicides were analyzed. The median number of firearm-related homicides per year decreased from 333 (PRE) to 199 (BAN) (p = 0.008). This effect persisted following expiration of the ban (BAN 199 vs POST 206, p = 0.429). The rate of firearm-related homicides per 1 M population also decreased from 119.4 in 1985 to 49.2 in 2014 (ß = -2.73, p < 0.0001). CONCLUSIONS: During the FAWB, there was a significant decrease in firearm-related homicides in three of the most dangerous cities, underscoring the need for better directed prevention efforts.

In for a Penny, in for a Pound: Obesity weighs heavily on both cost and outcome in trauma.

BACKGROUND: The current literature offers mixed conclusions regarding the effect of increased body mass index (BMI) on outcomes after trauma laparotomy. This study evaluated the impact of obesity on outcomes and cost for patients undergoing trauma laparotomy at a level 1 trauma center. STUDY DESIGN: Data on patients requiring trauma laparotomy in 2016 were prospectively collected and patients were stratified by BMI. Statistical analyses were used to determine variables significantly associated with patient morbidity and length of stay. RESULTS: 313 patients underwent trauma laparotomy: 225 non-obese, 69 obese, and 19 morbidly obese. Obese and morbidly obese patients had longer ICU and hospital lengths of stay (LOS), more ventilator days, larger hospital costs, and higher morbidity compared to non-obese patients. Obesity was an independent predictor for patient morbidity, ICU, and hospital LOS. CONCLUSIONS: Morbidity and length of stay increased with worsening obesity after trauma laparotomy, contributing to rising hospital costs.

Impact of Endovascular Stenting on Outcomes in Patients with Traumatic Subclavian Artery Injury.

BACKGROUND: Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI. STUDY DESIGN: Patients undergoing procedures for traumatic SAI were identified from the Trauma Quality Improvement Program database between 2015 and 2018. Demographics, severity of injury and shock, type of subclavian repair (open vs endovascular), morbidity, and mortality were recorded. Patients with SAI were stratified by mechanism and type of repair and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality. RESULTS: Seven hundred thirty-seven patients undergoing procedures for SAI were identified. Of these, 39% were penetrating. The majority were male (80%) with a median age and Injury Severity Score (ISS) of 37 and 21, respectively. 58% of patients were managed endovascularly. For patients with blunt injury, the type of repair affected neither morbidity (25% vs 19%, p = 0.116) nor mortality (11% vs 10%, p = 0.70). For patients with penetrating injuries, endovascular repair had significantly lower morbidity (12% vs 22%, p = 0.028) and mortality (6% vs 21%, p = 0.001). MLR identified endovascular repair as the only modifiable risk factor associated with reduced mortality (odds ratio, 0.35; 95% confidence interval, 0.14 to 0.87, p = 0.02). CONCLUSIONS: SAI results in significant morbidity and mortality regardless of mechanism. Although the type of repair did not affect mortality in patients with blunt injury, endovascular repair was identified as the only modifiable predictor of reduced mortality in patients with penetrating injuries.

Re-Sighting the Gun Debate: Defining Patterns of Firearm-Related Death to Help Focus Prevention Efforts.

BACKGROUND: Gun violence remains a significant public health problem. Although gun violence prevention efforts mostly target homicides, nationally, two-thirds of all firearm deaths are suicides. The purpose of this study was to define patterns of firearm-related deaths and examine the effect of population size. STUDY DESIGN: All firearm-related deaths in the US between 1999 and 2016 were analyzed. Homicides and suicides were obtained from the Federal Bureau of Investigation and the Centers for Disease Control and Prevention, respectively, comprising the database. For each state, the largest metropolitan city by population and a corresponding small urban city were selected. Firearm-related deaths were stratified by type and city size and compared. Rates of firearm-related homicides and suicides per 1 million population were stratified by year and compared over time using simple linear regression. RESULTS: 544,749 firearm-related deaths occurred across the US over the study period (38% homicides, 62% suicides). The median rate of firearm-related suicides was significantly greater than firearm-related homicides regardless of city size and across the US. Linear regression analysis failed to identify a significant change in the rate of firearm-related homicides over the study period. However, the rate of firearm-related suicides increased significantly regardless of city size between 1999 and 2016. CONCLUSION: Although homicides account for the majority of firearm-related deaths in metropolitan areas, suicides constitute a disproportionate number in smaller urban areas. Although the rate of homicides has stabilized, the rate of firearm-related suicides continues to increase significantly, underscoring the need for better direct prevention efforts and public health policy.

Serial CT for Nonoperatively Managed Splenic Injuries.

INTRODUCTION: The role of serial computed tomography (CT) in the nonoperative management of blunt splenic injuries (NOMSIs) remains unclear. The purpose of the study was to determine the utility of serial CT of Grade 2-5 NOMSI in the modern era. METHODS: Blunt splenic injuries were identified over a 3.5-year period, ending in 6/2020. Our institutional protocol for NOMSI mandates a repeat 24-hour CT for Grade 2-5 injuries. Patients age<18, Grade 1 injuries and patients that underwent intervention prior to repeat scan were excluded. Demographics, comorbidities, timing of events (admission, CTs, splenectomy, and angiography), injury details, procedural details, total transfusion requirements, complications, length of stay, mortality, and discharge disposition were recorded. Descriptive statistics were performed. RESULTS: 219 patients with Grade 2-5 NOMSI had both an initial and 24-hour CT after exclusions. 24-hour CT identified 14 patients with new PSA(s) and 11 (5%) went to angiography within 24 hours with 9 (4%) undergoing angioembolization and 4 (2%) had splenectomy. Two hundred and four (93%) had no intervention though eventually 12 went on to angiography and 6 went for splenectomy. The 24-hour CT rarely altered management in the absence of clinical indication or prior PSA on initial CT with 5 (2%) receiving a therapeutic embolization and 2 (1%) had a nontherapeutic angiogram. No deaths were attributable to splenic injury. CONCLUSIONS: Routine 24-hour CT for NOMSI did not impact management. Clinical status and change in exam may warrant repeat CT in select cases in the setting of a plausible alternate explanation. Prompt angioembolization or splenectomy is more appropriate in clear-cut cases of failed NOMSI.

Delayed Endovascular Repair With Procedural Anticoagulation: A Safe Strategy for Blunt Aortic Injury.

BACKGROUND: Blunt aortic injury (BAI) and traumatic brain injury (TBI) are the leading causes of death after blunt trauma. The purposes of this study were to identify predictors of mortality for BAI and to examine the impact of procedural heparinization during thoracic endovascular aortic repair (TEVAR) on neurologic outcomes in patients with BAI/TBI. METHODS: Patients with BAI were identified over an 8 year period. Age, gender, severity of injury and shock, time to TEVAR, morbidity, and mortality were recorded and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of mortality. Youden's index determined optimal time to TEVAR. RESULTS: A total of 129 patients were identified. The majority (74%) were male with a median age and injury severity score (ISS) of 40 years and 29, respectively. Of these, 26 (20%) had a concomitant TBI. Patients with BAI/TBI had higher injury burden at presentation (ISS 37 vs. 29, P = 0.002; Glasgow Coma Scale [GCS] 6 vs. 15, P < 0.0001), underwent fewer TEVAR procedures (31 vs. 53%, P = 0.039), and suffered increased mortality (39 vs. 16%, P = 0.009). All TEVARs had procedural anticoagulation, including patients with TBI, without change in neurologic function. The optimal time to TEVAR was 14.8 hr. Mortality increased in TEVAR patients before 14.8 hr (8.7 vs. 0%, P = 0.210). MLR identified TEVAR as the only modifiable factor that reduced mortality (odds ratio 0.11; 95% confidence interval 0.03-0.45, P = 0.002). CONCLUSIONS: TEVAR use was identified as the only modifiable predictor of reduced mortality in patients with BAI. Delayed TEVAR with the use of procedural heparin provides a safe option regardless of TBI with improved survival and no difference in discharge neurologic function.

Inflammatory and environmental contributions to social information processing.

It appears that social information processing is negatively affected by inflammation, but extant research is primarily experimental and comes from laboratory-based manipulations of inflammatory states. We aimed to examine interactions between inflammation, stressful life events, and positive memories of childhood relations with parents in relation to social information processing in 201 adults. We hypothesized that increased inflammation and stressful life events would be associated with greater hostile social information processing, but that positive memories of childhood relations with parents would moderate both relations. Results indicated that high IL-6 levels and stressful life events were significantly associated with direct and hostile social information processing. Positive memories of childhood relations with parents attenuated the link between stressful life events and social information processing. Findings suggest that both immune function and environmental stressors are related to social information processing and that positive memories of childhood relations exert some buffering effect.

Impact of Chemoprophylaxis on Thromboembolism Following Operative Fixation of Pelvic Fractures.

BACKGROUND: Venous thromboembolism (VTE) is a common cause of serious morbidity and mortality. While chemoprophylaxis decreases VTE, there is the theoretical risk of increased hemorrhagic complications. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt pelvic fractures requiring operative fixation. METHODS: Patients with blunt pelvic fractures requiring operative fixation over 10.5 years were identified. Patients were stratified by age, severity of shock, operative management, and timing and duration of anticoagulation. Outcomes were evaluated to determine risk factors for bleeding complications and VTE. RESULTS: 310 patients were identified: 212 patients received at least one dose of preoperative anticoagulation and 98 received no preoperative anticoagulation. 68% were male with a mean injury severity score and Glasgow Coma Scale of 26 and 13, respectively. Bleeding complications occurred in 24 patients and 21 patients suffered VTE. Patients with VTE had a greater initial severity of shock (resuscitation transfusions, 4 vs. 2 units, P = .02). Despite longer time to mobilization (4 vs. 3 days, P = .001), patients who received their scheduled preoperative doses within 48 hours of arrival had no significant differences in the number of deep vein thrombosis events (5.2% vs. 5.7%, P = .99), but fewer episodes of pulmonary embolism (PE) (1.5% vs. 6.8%, P = .03) with no difference in bleeding complications (7.5% vs. 8%, P = .87) compared to either patients who had their doses held until after 48 hours of arrival or received no preoperative anticoagulation. DISCUSSION: Preoperative anticoagulation prior to pelvic fixation reduced the risk of PE without increasing bleeding complications. Preoperative anticoagulation is safe and beneficial in this group of patients.

Examining the Relationship Between Victimization, Psychopathy, and the Acceptance of Rape Myths.

Rape myths are attitudes that implicitly and explicitly blame victims for their own sexual victimization. Greater adherence to rape myths is linked to several negative outcomes, including the neutralization of gender-based violence and the perpetration of sexual violence. Few studies have considered how previous life experiences and individual-level traits influence the development and greater adherence to rape myths. The current study examines how traits associated with the three-factor model of psychopathy (i.e., egocentric, callous, and antisocial dimensions) and adherence to traditional gender roles mediate the relationship between prior childhood/adolescent victimization and the acceptance of rape myths in a sample of college men and women (N = 789). Path modeling indicates that experiences of psychological victimization (before age 16) increased egocentric psychopathic traits, which then increased the acceptance of rape myths in men. In women, however, sexual victimization (before age 16) increased the acceptance of traditional gender roles, which then influenced the acceptance of rape myths. Additionally, the egocentric facet of psychopathy exerted indirect effects on the acceptance of rape myths through traditional views on gender roles in both men and women. These findings highlight the need to continue to examine egocentric personality traits in relation to the development of rape myths in adolescent and young adult populations. Directions for collegiate programming are discussed.

Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes.

BACKGROUND: Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS: Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS: One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION: Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE: Prognostic study, Level IV.

An exploratory analysis of testosterone, cortisol, and aggressive behavior type in men and women.

Increasing evidence indicates that the interaction between testosterone and cortisol is associated with variation in aggressive behavior. However, results are mixed. The current study further explored the association between testosterone, cortisol, and both reactive and proactive aggression in a large sample of university students. Models considered direct and interactive effects between baseline measures of testosterone and cortisol as well as change in hormones in response to a social stressor. In women, baseline cortisol had a negative direct association with reactive aggression and was further associated with reactive aggression in interaction with baseline testosterone (positive interaction). Hormones were unrelated to reactive aggression in men. Baseline cortisol had a negative direct association with proactive aggression in women. In contrast, the association between change in cortisol and proactive aggression was positive. Cortisol was not associated with proactive aggression in men. In addition, testosterone was not related to proactive aggression either directly or in interaction with cortisol in either men or women. Collectively, these results show that the association between hormones and aggression varies across aggressive behavior type and across sex.

Caught in the crossfire: 37 Years of firearm violence afflicting America's youth.

INTRODUCTION: Publicly available firearm data are difficult to access. Trauma registry data are excellent at documenting patterns of firearm-related injury. Law enforcement data excel at capturing national violence trends to include both circumstances and firearm involvement. The goal of this study was to use publicly available law enforcement data from all 50 states to better define patterns of firearm-related homicides in the young. METHODS: All homicides in individuals 25 years or younger in the United States over a 37-year period ending in 2016 were analyzed: infant, 1 year or younger; child, 1 to 9 years old; adolescent, 10 to 19 years old; and young adult, 20 to 25 years old. Primary data files were obtained from the Federal Bureau of Investigation and comprised the database. Data analyzed included homicide type, situation, circumstance, month, firearm type, and demographics. Rates of all homicides and firearm-related homicides per 1 million population and the proportion of firearm-related homicides (out of all homicides) were stratified by year and compared over time using simple linear regression. RESULTS: A total of 171,113 incidents of firearm-related homicide were analyzed (69% of 246,437 total homicides): 5,313 infants, 2,332 children, 59,777 adolescents, and 103,691 young adults. Most (88%) were male and Black (59%) with a median age of 20 years. Firearm-related homicides peaked during the summer months of June, July, and August (median, 1,156 per year; p = 0.0032). Rates of all homicides (89 to 53 per 1 million population) and firearm-related homicides (56 to 41 per 1 million population) decreased significantly from 1980 to 2016 (ß = -1.12, p < 0.0001 and ß = -0.57, p = 0.0039, respectively). However, linear regression analysis identified a significant increase in the proportion of firearm-related homicides (out of all homicides) from 63% in 1980 to 76% in 2016 (ß = 0.33, p < 0.0001). CONCLUSION: For those 25 years or younger, the proportion of firearm-related homicides has steadily and significantly increased over the past 37 years, with 3 of 4 homicides firearm related in the modern era. Despite focused efforts, reductions in the rate of firearm-related homicides still lag behind those for all other methods of homicide by nearly 50%. That is, while the young are less likely to die from homicide, for those unfortunate victims, it is more likely to be due to a firearm. This increasing role of firearms in youth homicides underscores the desperate need to better direct prevention efforts and firearm policy if we hope to further reduce firearm-related deaths in the young. LEVEL OF EVIDENCE: Epidemiological study, level III.

Further Evaluation of the Associations Between Psychopathic Traits and Symptoms of PTSD and Depression in a Nonclinical Sample.

Examining psychopathic traits at the factor or facet level has revealed that various aspects of psychopathy may be differentially related, even in opposing directions, to important outcomes (e.g., intelligence, emotion regulation). Empirical work on relations between psychopathy and internalizing disorders, such as posttraumatic stress disorder (PTSD) and depression, has provided evidence for a positive association with antisocial traits. However, findings for the affective domain have been more equivocal. The current study (N = 732) sought to replicate past findings of the positive association of antisocial psychopathic traits with higher levels of PTSD and depressive symptoms, and to further explore associations between affective traits of psychopathy and these disorders using two measures of psychopathy. Results confirmed prior findings of a positive correlation between antisocial features and self-reported PTSD/Depression symptom severity, but they did not provide evidence for any association with affective traits. Future research using longitudinal designs is needed to begin establishing temporal ordering of the psychopathy-internalizing relationship.

Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury.

BACKGROUND: Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset. STUDY DESIGN: Patients with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 10 years, ending in 2016. Patients with BAI were stratified by the presence of concomitant TBI and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in BAI patients with and without TBI. Youden's index was used to identify the optimal time to TEVAR in these patients. RESULTS: 17,040 patients with BAI were identified, with 4,748 (28%) having a TBI. Patients with BAI and TBI were predominantly male, with a higher injury burden and greater severity of shock at presentation, underwent fewer TEVAR procedures, and had increased mortality compared with BAI patients without TBI. The optimal time for TEVAR was 9 hours. Mortality was significantly increased in patients undergoing TEVAR before 9 hours (12.9% vs 6.5%, p = 0.003). For BAI patients with and without TBI, MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (odds ratio [OR] 0.41; 95%CI 0.32-0.54, p < 0.0001). CONCLUSIONS: TBI significantly increases mortality in BAI patients. TEVAR and delayed repair both significantly reduced mortality. So, for patients with both BAI and TBI, an endovascular repair performed in a delayed fashion should be the preferred approach.