bluuebunny/crossref_metadata_2025 huggingface dataset:
Analysis on the Supply Willingness of Mortgage Loan of Farmland Management Right under the Government-Led Mode in China Western’s Region
Authors: Niu Rong , Yan Xiao
Published: December 2020

In this paper, the Probit model was established based on the survey data of 105 loan officers in China’s Western Region, and the factors influencing the willingness of mortgage loan supply of farmland management rights under the government-led model were investigated from the perspective of financial supply. The research shows that farmers’ income, farmers’ policy awareness, farmland scale, loan experience, risk compensation system, legal perfection and policy stability have a positive impact on the willingness of loan officers to issue mortgage loans for farmland management rights. Factors such as farmers’ age and education level have a negative impact on the willingness to supply. In addition, by comparing the stability of the regression model before and after the addition of risk compensation system, legal perfection degree and policy stability degree, it is concluded that the policy variables have a great influence on the decision-making of financial institutions.
“The Main Parts Are Made in Europe”: Apologetic/Critical Dichotomy and the Untold Story of Qur’anic Studies in the Iranian Academy
Authors: Feyzbakhsh Mohsen
Published: December 2020

This response to Majid Daneshgar’s book develops his argument about apologetics in the study of the Qur’an in the Muslim Academy in two ways. First, it makes a distinction between two different senses of the term apologetics and then shows how each sense would be relevant to Daneshgar’s argument. Second, it applies the argument to Islamic studies in the Iranian Academy in particular.
Twenty Years of Triumph, Trial and Tribulation: Reflections on the Mechanism of the African Commission’s Special Rapporteur on the Rights of Women in Africa
Authors: Kariseb Kennedy
Published: December 2020

On the occasion of its 25th Ordinary Session held in Bujumbura, Burundi, from 26 April to 5 May 1999, the African Commission adopted resolution ACHPR/res.38 (XXV) 99 on the appointment of a Special Rapporteur on the Rights of Women in Africa (SRRWA), retrospectively with the appointment taking effect from 31 October 1998. This means that the mechanism of the SRRWA is roughly making twenty years since its initial inception. Coming of age and time, the twenty years of existence of the mechanism of the SRRWA makes it not only one of the oldest (and perhaps most successful) mechanisms of the African Commission; but one that has been the subject of tremendous triumph, trial and tribulation. Over the past two decades, the mechanism has been a product of both progression and regression. By and large the mechanism of the SRRWA has played an appreciable role in the advancement of women’s rights on the African continent. This article aims at taking stock of the achievements and failures of the 20 years of the work of the SRRWA. Although taking pride in the achievements of the mechanism, this article argues for incremental reforms within the mechanism, including the refining of the terms of reference of the mandate; the need for closer cooperation with global and regional systems mechanisms, women at grassroots including women’s rights movements, and mutual support from civil society organisations.
The Interior Frontiers of Germany
Authors: Hernández Aguilar Luis Manuel
Published: December 2020

In 2012, the regional court of the city of Cologne ruled that ritual male circumcision constituted unjustified bodily harm. This prompted a nationwide debate culminating in the enactment of legislation guaranteeing male circumcision without medical justification under certain preconditions. This article proposes to approach the ‘circumcision debate’ as a discursive strand of the systematic problematisation of Muslims as ‘Muslims’, which I analyse through the analytic of the ‘Muslim Question’. In addition, I refer to the concepts of recursive history and of the interior frontier to contextualise the 2012 circumcision debate and the political purpose it has served, namely, to establish racial distinctions and interior frontiers between Germans, Jews and Muslims.
Exploration of Middle School Students’ Ideas of Fine Dust Issues Using Issue Concept Maps
Authors: Kim Gahyoung , Mun Kongju , Lee Hyunju
Published: December 2020

This study introduces issue concept maps (IC map) as an instructional tool for exploring students’ idea about socio-scientific issues (SSI). By visualizing students’ ideas in two dimensions, context and occurrence, IC maps represent what kinds of ideas students have on the issues, and how their ideas change and connect. In the study, we implemented a SSI program on fine dust for 77 seventh graders and used IC maps to investigate how their ideas changed after the program. Students collaboratively constructed IC maps in groups before and after the program. Results show that the number of ideas written on IC maps significantly increased after the program from 92 to 254 ideas, indicating that the program contributed to enhancing students’ awareness about the issues in terms of its causes, effects, and countermeasures at various context levels. Students also presented a greater variety of types of connections among their ideas after the program.
Current Trends in Surgical Procedures Performed in Rural General Surgery Practice
Authors: Stinson Wade W. , Sticca Robert P. , Timmerman Gary L. , Bjordahl Paul M.
Published: December 2020

Background

The procedures that rural general surgeons perform may be changing. It is important to recognize the trends and practices of the current rural general surgeon in efforts to better prepare general surgeons who desire to enter a practice in a rural environment. The aim of this review is to detail the recent operative case volumes of 6 rural locations in the upper Midwest where general surgery is practiced.

Methods

The Enterprise Data and Analytics department of Sanford Health compiled all surgical procedures performed within the Sanford Health System between January 1, 2013 and August 31, 2018. Procedures performed by a total of 58 general surgeons in locations of under 50 000 people are included in this review.

Results

From January 1, 2013 to August 31, 2018, 38 958 surgical procedures were performed in rural locations. Endoscopic procedures made up 61.6% of a rural general surgeon’s practice. Cholecystectomy (6.3%), hernia repair (6.3%), and appendectomy (3.7%) were the principle nonendoscopic procedures performed by rural surgeons, comprising 16.3% of the case volume. Added together, endoscopy, cholecystectomy, hernia repair, and appendectomy made up 77.9% of the rural general surgeon’s caseload. Vascular procedures (2.5%), breast procedures (1.8%), obstetrics (0.4%), and urology procedures (0.2%) are also included in this review.

Conclusions

Rural general surgeons are vital to the surgical workforce in the United States. Recognizing a trend that rural general surgeons perform less subspecialty procedures and more endoscopic procedures will provide direction for those interested in pursuing a career in rural general surgery.
Three Risk Stratification Tools and Postoperative Pneumonia After Noncardiothoracic Surgery
Authors: Laporta Mariana L. , Kruthiventi S. Chandralekha , Mantilla Carlos B. , Johnson Rebecca L. , Sprung Juraj , Portner Erica R. , Schroeder Darrell R. , Weingarten Toby N.
Published: December 2020

Background

Postoperative in-hospital pneumonia is a serious complication. This study aims to investigate the association between 3 preoperative stratification tools (American Society of Anesthesiologists Physical Status [ASA-PS] score, Charlson Comorbidity Index [CCI], and Rockwood Frailty Deficit Index [FI]) and risk for postoperative pneumonia.

Methods

We identified adult patients who developed postoperative pneumonia following noncardiothoracic surgery under general anesthesia, between January 1, 2016 and December 31, 2017. Patients with postoperative pneumonia were 1:1 matched to control subjects based on age, sex, and the exact type of operations. Medical records were reviewed to identify variables that may be associated with risk for developing postoperative pneumonia. Analyses adjusted for clinical characteristics were performed using the conditional logistic regression, taking into account 1:1 matched set case-control study design.

Results

We identified 211 cases of postoperative pneumonia, and all 3 tested stratification tools were associated with increased risk: ASA-PS (after all adjustments of American Society of Anesthesiologists (ASA) III, odds ratio 4.17 [95% confidence interval 1.74-10.01]; ASA > III 24.03 [6.54-88.32]), CCI (CCI values > 3, 1.29 [1.02-1.63] per unit CCI score), and frail FI score 3.25 (1.45-7.27). Because of incomplete intake documentation, the FI could not be calculated in 57 (13.5%) patients, but these “unknown frailty” patients were also at increased risk for postoperative pneumonia, 3.15 (1.29-7.72).

Discussion

Three commonly used stratification indices (ASA-PS score, CCI, and FI) were associated with increased risk for postoperative pneumonia. Patients unable to complete intake form to calculate the FI were also at increased risk.
Modern Management of Perianal Crohn’s Disease: A Review
Authors: Williams Jennifer L. , Shaffer Virginia O.
Published: December 2020

Perianal Crohn’s disease (CD) is a complex manifestation of CD that affects approximately 10% of patients. The spectrum of disease is quite variable, ranging from relatively mild disease to severe, aggressive manifestations that result in frequent hospitalizations, multiple surgeries, and poor quality of life. Despite significant recent advances in surgical and medical management, treatment remains challenging and frequently requires a multidisciplinary medical-surgical approach. The goal of this article is to review the current literature regarding the work-up, treatment, and future directions of therapy. Crucial features of effective management include the precise identification of manifestations, control of sepsis, limiting rectal inflammation, frequently with use of antitumor necrosis factor agents, and avoidance of extensive surgery.
Comparing Surgical Outcomes Among Patients Admitted for Small Bowel Obstruction on Weekend vs. Weekday
Authors: Butensky Samuel D. , Hui Shirley Y. , Alfonso Antonio E. , Coppa Gene F. , Sugiyama Gainosuke , Chung Paul
Published: December 2020

Introduction

Surgical intervention is important in reducing morbidity and mortality among patients admitted for small bowel obstruction (SBO). Patient-specific variables such as age and comorbidities are risk factors for adverse outcomes after surgery for SBO. However, the effect of weekend admission on outcomes has not been well delineated in the literature. Our aim was to determine whether weekend admission affects mortality and length of stay (LOS) in patients who were admitted for SBO and were managed operatively.

Materials and Methods

Using the 2006-2012 Nationwide Inpatient Sample (NIS) database, we identified adult patients who were admitted with a primary diagnosis of SBO and had a primary procedure of exploratory laparotomy, lysis of adhesions, or small bowel resection. We performed univariate analysis comparing cases that were admitted on the weekend vs. weekday. We then performed negative binomial regression with LOS as the dependent variable, adjusting for risk variables.

Results

2804 patients were studied, of which 728 (26.0%) were admitted on the weekend. Univariate analysis showed no statistically significant difference in mortality or LOS for patients admitted on a weekday vs. weekend. Multivariate analysis showed that several factors were associated with increased LOS, including third quartile van Walraven score ( P < .0001) and large hospital size ( P = .0031). Other factors were associated with decreased LOS, including fourth quartile of income ( P = .0022) and weekend admission ( P = .048).

Discussion

There is no significant difference in mortality between patients admitted on weekend vs. weekday for SBO, but patients admitted on weekend are more likely to have a decreased LOS.
Outcomes in Delayed Drainage of Hemothorax
Authors: Weaver Jessica L. , Kaufman Elinore J. , Young Andrew J. , Keating Jane J. , Subramanian Madhu , Cannon Jeremy W. , Shiroff Adam , Seamon Mark J.
Published: December 2020

Background

Prompt drainage of traumatic hemothorax is recommended to prevent empyema and trapped lung. Some patients do not present the day of their trauma, leading to their delayed treatment. Delayed drainage could be challenging as clotted blood may not evacuate through a standard chest tube. We hypothesized that such delays would increase the need for surgery or secondary interventions.

Methods

Our trauma registry was reviewed for patients with a hemothorax admitted to our level 1 trauma center from 1/1/00 to 4/30/19. Patients were included in the delayed group if they received a drainage procedure >24 hours after injury. These patients were matched 1:1 by chest abbreviated injury score to patients who received drainage <24 hours from injury.

Results

A total of 19 patients with 22 hemothoraces received delayed drainage. All but 3 patients had a chest tube placed as initial treatment. Four patients received surgery, including 3 who initially had chest tubes placed. Longer time to drainage increased the odds of requiring intrathoracic thrombolytics or surgery. In comparison, 2 patients who received prompt drainage received thrombolytics ( P = .11) and none required surgery ( P = .02). Patients needed surgery when initial drainage was on or after post-injury day 5, but pigtail catheter drainage was effective 26 days after injury.

Discussion

Longer times from injury to intervention are associated with increased likelihood of needing surgery for hemothorax evacuation, but outcomes were not uniform. A larger, multicenter study will be necessary to provide better characterization of treatment outcomes for these patients.
The Effect of Organ System Surgery on Intensive Care Unit Mortality in a Cohort of Critically Ill Surgical Patients
Authors: Shchatsko Anastasiya , Purcell Laura N. , Tignanelli Christopher J. , Charles Anthony
Published: December 2020

Background

The critical illness burden in the United States is growing with an aging population obtaining surgical intervention despite age-related comorbidities. The effect of organ system surgical intervention on intensive care units (ICUs) mortality is unknown.

Methods

We performed an 8-year retrospective analysis of surgical ICU patients. Poisson regression analysis was performed assessing the relative risk of in-hospital mortality based on surgical intervention.

Results

Of 468 000 ICU patients included, 97 968 (20.9%) were surgical admissions and 97 859 (99.9%) had complete outcomes data. Nonsurvivors were older (68.8 ± 15.4 vs. 62.7 ± 15.8 years, P < .001) with higher Acute Physiology, Age, Chronic Health Evaluation (APACHE) III Scores (81.4 ± 33.6 vs. 46.7 ± 20.1, P < .001. Patients with gastrointestinal (GI) (n = 1,558, 7.8%), musculoskeletal (n = 277, 5.5%), and neurological (n = 884, 4.6%) system operations had the highest mortality. Upon Poisson regression model, patients undergoing emergent operative interventions on the neurologic system (RR 1.86, 95% CI 1.67-2.07, P < .001) had increased relative risk of mortality when compared to emergent operative interventions on the cardiovascular system after controlling for pertinent covariates. Elective operative interventions on the respiratory (RR 2.39, 95% CI 2.03-2.80, P < .001), GI (RR 2.34, 95% CI 2.10-2.61, P < .001), and skin and soft tissue (RR 2.26, 95% CI 1.77-2.89, P < .001) systems had increased risk of mortality when compared to elective cardiovascular system surgery after controlling for pertinent covariates.

Conclusion

We found significant differences in the risk of mortality based on organ system of operative intervention. The prognostication of critically ill patients undergoing surgical intervention is currently not accounted for in prognostic scoring systems.
Facility of Origin Predicts Mortality After Colonic Perforation
Authors: Butensky Samuel D. , Gazzara Emma , Sugiyama Gainosuke , Coppa Gene F. , Alfonso Antonio , Chung Paul J.
Published: December 2020

Introduction

Colonic perforation often requires emergent intervention and carries high morbidity and mortality. The objective of this study was to determine whether nonclinical factors, such as transition of care from outpatient facilities to inpatient settings, are associated with increased risk of mortality in patients who underwent emergent surgical intervention for colonic perforation.

Materials and Methods

Using the 2006-2015 ACS National Surgical Quality Improvement Program database, we identified adult patients who underwent emergent partial colectomy with primary anastomosis ± protecting ostomy or partial colectomy with ostomy with intraoperative finding of wound class III or IV for a diagnosis of perforated viscus. The outcome of interest was 30-day postoperative mortality. Univariate and multivariate analyses using logistic regression were performed.

Results

4705 patients met criteria, of which 841 (17.9%) died. Univariate analysis showed that patients who died after emergent surgery for perforated viscus were more likely to present from a chronic care facility (13.4% vs. 4.4%, P < .0001) and had longer time from admission to undergoing surgery (mean 4.1 vs. 2.0 days, P < .0001. Logistic regression demonstrated that septic shock vs. none (OR 3.60, P < .0001), sepsis vs. none (OR 1.57, P = .00045), transfer from chronic care facility vs. home (OR 1.87, P < .0001), and increased time from admission vs. operation (OR 1.01, P = .0055) were independently associated with increased risk of death.

Discussion

Transfer from a chronic care facility was independently associated with increased mortality in patients undergoing emergent surgery for perforated viscus.
Pathologic Complete Response Following Neoadjuvant Therapy for Gastric Adenocarcinoma: A National Cancer Database Analysis on Incidence, Predictors, and Outcomes
Authors: Kaltenmeier Christof , Althans Alison , Mascara Maria , Nassour Ibrahim , Khan Sidrah , Hoehn Richard , Zureikat Amer , Tohme Samer
Published: December 2020

Introduction

With advances in multimodal therapy, survival rates in gastric cancer have significantly improved over the last two decades. Neoadjuvant therapy increases the likelihood of achieving negative margins and may even lead to pathologic complete response (pCR). However, the impact of pCR on survival in gastric cancer has been poorly described. We analyzed the rate and predictors of pCR in patients receiving neoadjuvant therapy as well as impact of pCR on survival.

Methods

We conducted a National Cancer Database (NCDB) analysis (2004-2016) of patients with gastric adenocarcinoma who received neoadjuvant chemotherapy followed by surgical resection.

Results

The pCR rate was 2.2%. Following adjustment, only neoadjuvant chemoradiation, non-signet histology, and tumor grade remained as significant factors predicting pCR. pCR was a statistically significant predictor of survival.

Conclusion

In this NCDB study, pCR was a predictor of survival. Though chemoradiation rather than chemotherapy alone was a predictor of pCR, it was not a predictor of survival. Further studies are needed to elucidate the role of radiation in the neoadjuvant setting and to discern the impact of pCR on survival.
Social Media in Surgery
Authors: Harrell Kevin N. , Vervoort Dominique , Luc Jessica G.Y. , Tracy Brett M. , Daniel Stanley John
Published: December 2020

Social media has become a permeating form of communication with billions of daily users. Twitter in particular has become a tool for the surgical community to engage with other providers, as well as patients, through active online discussions, sharing of research, and highlighting opportunities for community outreach. Twitter can help with personal branding, mentorship, and international collaboration on multiple types of academic endeavors. Likewise, institutional and residency programs can harness the power of social media to develop an online presence and aid in resident recruitment.
Surgical Intensivist-Led Training in Critical Care Ultrasound Improves Performance
Authors: Lauerman Margaret H. , Haase Daniel J. , Teeter William , Kufera Joseph , Ghneim Mira , Betzold Richard , Scalea Thomas , Murthi Sarah
Published: December 2020

Background

Critical care ultrasound (CCUS) is essential in modern practice, with CCUS including cardiac and noncardiac ultrasound. The most effective CCUS training is unknown, with a diverse skill set and knowledge needed for competence. The objective of this project was to evaluate the effect of a surgical intensivist-led training program on CCUS competence in critical care fellows.

Methods

This was a single institution retrospective review from 2016 to 2018 at the R Adams Cowley Shock Trauma Center. Our yearlong surgical intensivist (SI)-led CCUS training program for critical care fellows includes a daylong CCUS training class, CCUS lectures, a CCUS rotation, and bedside CCUS instruction during rotations. Fellows take a knowledge test and skills test before (pretest) and after (posttest) this program. Critical care ultrasound skill was graded on a scale from 1-5, with 4 (minimal help) or 5 (no help) considered competent. Emergency medicine, surgery, and medicine-trained critical care fellows were included.

Results

Forty-two critical care fellows were included. Mean posttest scores increased significantly for 21/22 (96%) of skills tested and for 14/30 (47%) of knowledge questions compared to pretest scores. The mean composite skill score increased from 3.25 to 4.82 from pretest to posttest ( P < .001). The mean composite knowledge score increased from 60% to 80% from pretest to posttest ( P < .001).

Conclusion

SI-led training improves CCUS competence and knowledge despite the breadth of CCUS.
Utilizing Oral Surveys to Better Understand Patient Satisfaction in a Low-Income, Urban Surgical Clinic
Authors: Miller Parker A. , Burgoon Montgomry L. , Hoover-Hankerson Bryson , Strand Nicolle , Ross Howard
Published: December 2020

Oral surveys allow patients to elaborate on their experience in the hospital, giving context to numerical values often used to assess patient satisfaction. This allows patients to speak about factors affecting satisfaction, which is important in complex, low-income populations. Spoken surveys were administered to 80 patients in surgery clinics at Temple University Hospital. Responses were transcribed and coded to analyze patient responses. Relationships among patient responses were identified, and responses were categorized to determine the most important factors related to patient satisfaction. Numerical data were also used to assess satisfaction. Patients were satisfied with their experience with the physician and the hospital, reporting averages scores of 9.73 and 9.19, respectively. Regarding physician satisfaction, patients cited effective communication and professionalism as being most important. As long as nothing went wrong, patients scored their experience outside their interactions with the physician highly. Negative experiences were mainly related to wait times and ineffective communication with office staff and were seldom related to the physician. By using a spoken survey, patients could elaborate on their responses which provides context to the numerical data. Despite the positive feedback for physicians, patients spoke openly about communication. In low-income populations, communication failures can be exacerbated by the power differential present between the patient and physician. Our study demonstrates the utility of oral surveys in understanding complex patient populations, and the results can be used to shape surgical and nonsurgical practices in similar patient populations.
Patient Comorbidities Drive High Mortality Rates Associated with Major Liver Resections Irrespective of Hospital Volume
Authors: Diggs Laurence P. , Aversa John G. , Wiemken Timothy L. , Martin Sean P. , Drake Justin A. , Ruff Samantha M. , Wach Michael M. , Brown Zachary J. , Blakely Andrew M. , Davis Jeremy L. , Luu Carrie , Hernandez Jonathan M.
Published: December 2020

Introduction

Major hepatectomies are utilized to manage primary hepatic malignancies. Reports from high-volume centers (HVCs) with minimal perioperative mortality focus on multiple aspects of perioperative care, although patient-specific factors remain unelucidated. We identified patient factors associated with outcomes and examined whether these contribute to survival differences.

Methods

We queried the National Cancer Database (2006-2015) for patients with primary liver malignancies managed with major hepatectomy. Facilities were dichotomized by volume (high volume: >15 hepatectomies/year). Perioperative outcomes were compared based on patient demographic and clinical characteristics as well as center volume.

Results

4263 patients were included with 78.5% receiving care in low-volume centers (LVCs). 90-day postoperative mortality was higher in LVCs vs. HVCs (12% vs. 7.5%; P < .001). Factors associated with undergoing surgery in LVCs included: living in areas with lower income ( P = .006) and education ( P < .001), having nonprivate insurance ( P < .001), residing near the care center ( P < .001), and having a comorbidity score (CDS) >1 ( P = .014). Patients with CDS ≤ 1 had higher 90-day mortality in LVCs (11.3% vs. 6.6%; P < .001) and had similar outcomes in LVCs and HVCs (15.6% vs. 13.7% P = .6). Patients with CDS > 1 were more likely to receive care in LVCs (16.3% vs. 12.7%; P < .001).

Conclusion

Reduced perioperative mortality following major hepatectomy in HVCs is driven by optimal management of patients with low CDS. However, nearly 1 in 5 patients who undergo major hepatectomies have a high CDS and approximately 15% of them succumb in the perioperative period irrespective of the treating centers’ experience.
Level of Comfort With Pediatric Trauma Transports: Survey of Prehospital Providers
Authors: Bayouth Lilly , Edgar Lauren , Richardson Brent , Ebler David , Tepas Joseph J. , Crandall Marie L.
Published: December 2020

Background

Unintentional injury is the leading cause of death in pediatric patients. Despite a heavy burden of pediatric trauma, prehospital transport and triage of pediatric trauma patients are not standardized. Prehospital providers report anxiety and a lack of confidence in transport, triage, and care of pediatric trauma patients.

Materials and Methods

Prehospital transport providers with 3 organizations across southeast Georgia and northeast Florida were contacted via email (n = 146) and asked to complete 2 Web-based surveys to evaluate their comfort level with performing tasks in the transport of pediatric and adult trauma patients. Bivariate statistics and qualitative thematic analyses were performed to assess comfort with pediatric trauma transports.

Results

Survey 1 (N = 35) showed that mean comfort levels of prehospital providers were significantly lower for pediatric patients than adult trauma patients in 7 out of 9 tasks queried, including airway management and interpreting children’s physiology. The following themes emerged from survey 2 (N = 14) responses: additional clinical knowledge resources would be beneficial when caring for pediatric trauma patients, pediatric medication administration is a source of uncertainty, prehospital transport teams would benefit from additional pediatric trauma training, infrequent transport of pediatric trauma patients affects provider comfort level, and pediatric trauma generates higher levels of anxiety among providers.

Discussion

Prehospital transport of pediatric trauma patients is infrequent and a source of anxiety for prehospital providers. Rigs should be equipped with a reference tool addressing crucial tasks and deficiencies in training.
Anemia at Intensive Care Unit Admission and Hospital Mortality Among Patients at a Referral Hospital in Malawi
Authors: Prin Meghan , Rui Shumin , Pan Stephanie , Kadyaudzu Clement , Mehta Parth S. , Li Guohua , Charles Anthony
Published: December 2020

Background

Anemia is associated with intensive care unit (ICU) outcomes, but data describing this association in sub-Saharan Africa are scarce. Patients in this region are at risk for anemia due to endemic conditions like malaria and because transfusion services are limited.

Methods

This was a prospective cohort study of ICU patients at Kamuzu Central Hospital (KCH) in Malawi. Exclusion criteria included age <5 years, pregnancy, ICU readmission, or admission for head injury. Cumulative incidence functions and Fine-Gray competing risk models were used to evaluate hemoglobin (Hgb) at ICU admission and hospital mortality.

Results

Of 499 patients admitted to ICU, 359 were included. The median age was 28 years (interquartile ranges (IQRs) 20-40) and 37.5% were men. Median Hgb at ICU admission was 9.9 g/dL (IQR 7.5-11.4 g/dL; range 1.8-18.1 g/dL). There were 61 (19%) patients with Hgb < 7.0 g/dL, 59 (19%) with Hgb 7.0-8.9 g/dL, and 195 (62%) with Hgb ≥ 9.0 g/dL. Hospital mortality was 51%, 59%, and 54%, respectively. In adjusted analyses, anemia was associated with hospital mortality but was not statistically significant.

Conclusions

This study provides preliminary evidence that anemia at ICU admission may be an independent predictor of hospital mortality in Malawi. Larger studies are needed to confirm this association.
Implications of the United States Medical Licensing Examination Step 1 Examination Transition to Pass/Fail on Medical Students Education and Future Career Opportunities
Authors: Ehrlich Haley , Sutherland Mason , McKenney Mark , Elkbuli Adel
Published: December 2020

Background

United States Medical Licensing Examination (USMLE) Step 1 will transition to pass/fail score by 2022. We aim to investigate US medical students’ perspectives on the potential implications this transition would have on their education and career opportunities.

Methods

A cross-sectional study investigating US medical students’ perspectives on the implications of transition of the USMLE Step 1 exam to pass/fail. Students were asked their preferences regarding various aspects of the USMLE Step 1 examination, including activities, educational opportunities, expenses regarding preparation for the examination, and future career opportunities.

Results

215 medical students responded to the survey, 59.1% were women, 80.9% were allopathic vs. 19.1% osteopathic students. 34.0% preferred the USMLE Step 1 to be graded on a pass/fail score, whereas 53.5% preferred a numeric scale. Osteopathic vs. allopathic students were more likely to report that the pass/fail transition will negatively impact their residency match (aOR = 1.454, 95% CI: 0.515, 4.106) and specialty of choice (aOR = 3.187, 95% CI: 0.980, 10.359). 57.7% of respondents reported that the transition to a pass/fail grading system will change their study habits.

Conclusions

The transition of the USMLE Step 1 to a pass/fail system has massive implications on medical students and residency programs alike. Though the majority of medical students did not prefer the USMLE Step 1 to have a pass/fail score, they must adapt their strategies to remain competitive for residency applications. Residency programs should create a composite score based off all aspects of medical students’ applications in order to create a holistic and fair evaluation and ranking system.
A Comparison of Colectomy Outcomes Utilizing Open, Laparoscopic, and Robotic Techniques
Authors: McCarthy Elizabeth , Gough Benjamin L. , Johns Michael S. , Hanlon Alexandra , Vaid Sachin , Petrelli Nicholas
Published: December 2020

Introduction

Robotic colectomy could reduce morbidity and postoperative recovery over laparoscopic and open procedures. This comparative review evaluates colectomy outcomes based on surgical approach at a single community institution.

Methods

A retrospective review of all patients who underwent colectomy by a fellowship-trained colon and rectal surgeon at a single institution from 2015 through 2019 was performed, and a cohort developed for each approach (open, laparoscopic, and robotic). 30-day outcomes were evaluated. For dichotomous outcomes, univariate logistic regression models were used to quantify the individual effect of each predictor of interest on the odds of each outcome. Continuous outcomes received a similar approach; however, linear and Poisson regression modeling were used, as appropriate.

Results

115 patients were evaluated: 14% (n = 16) open, 44% (n = 51) laparoscopic, and 42% (n = 48) robotic. Among the cohorts, there was no statistically significant difference in operative time, rate of reoperation, readmission, or major complications. Robotic colectomies resulted in the shortest length of stay (LOS) (Kruskal-Wallis P < .0001) and decreased estimated blood loss (EBL) (Kruskal-Wallis P = .0012). Median age was 63 years (interquartile range [IQR] 53-72). 54% (n = 62) were female. Median American Society of Anesthesiologists physical status classification was 3 (IQR 2-3). Median body mass index was 28.67 (IQR 25.03-33.47). A malignant diagnosis was noted on final pathology in 44% (n = 51).

Conclusion

Among the 3 approaches, there was no statistically significant difference in 30-day morbidity or mortality. There was a statistically significant decreased LOS and EBL for robotic colectomies.
Idiopathic Myointimal Hyperplasia of the Mesenteric Veins: A Rare Imitator of Inflammatory Bowel Disease
Authors: Kelly Wu W. , Tombazzi Claudio R. , Howe Catherine F. , Kendall Melissa A. , Walton Douglas B. , Washington Mary K. , Ford Molly M. , Hopkins Michael B. , Geiger Timothy M. , Hawkins Alexander T. , Muldoon Roberta L.
Published: December 2020

Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare cause of chronic colonic ischemia characterized by intimal smooth muscle proliferation and luminal narrowing of the small to medium sized mesenteric veins. It predominantly affects the rectosigmoid colon in otherwise healthy, middle-aged males. Definitive diagnosis and treatment are surgical; however, patients are frequently misdiagnosed, which often results in a protracted clinical course. We describe a case of IMHMV presenting as left hemicolitis in a 53-year-old male, as well as the endoscopic, histopathologic, and radiographic findings that established the diagnosis.
Intra-abdominal Inferior Vena Cava Injuries: Operative Strategies and Outcomes
Authors: Castater Christine A. , Carlin Margo , Parker Virginia S. , Sciarretta Chris , Koganti Deepika , Nguyen Jonathan , Grant April A. , Smith Randi N. , Ramos Christopher R. , Sciarretta Jason D. , Dente Christopher J. , Rajani Ravi , Todd Samual R.
Published: December 2020

Visceral vascular injuries are relatively uncommon even in busy urban trauma centers. The inferior vena cava (IVC) is the most frequently injured visceral vein and can be a complex operative challenge. Despite advances in early volume resuscitation, improved transport times, prompt operative intervention, and hemorrhage control, mortality rates have remained largely unchanged. This article conducts an in-depth review of the literature surrounding IVC injuries and a detailed discussion of operative strategies and management as survivability is ultimately dependent on the grade of injury, location, and the presence of hemorrhagic shock.
The Role of Nutritional Access in Malnourished Elderly Undergoing Major Surgery for Acute Abdomen: A Propensity Score-Matched Analysis
Authors: Gogna Shekhar , Samson David , Choi James , Con Jorge , Prabhakaran Kartik , Rhee Peter , Latifi Rifat
Published: December 2020

Background

About 50% of the elderly undergoing emergency abdominal surgery are malnourished. The role of timely surgical nutritional access in this group of patients is unknown.

Methods

We analyzed the National Inpatient Sample database from 2009 through the first three-quarters of 2015 of patients aged ≥65 years who were malnourished and underwent major abdominal surgery for the acute abdomen within the first 2 days of hospital admission.

Results

Of 3 246 721 patients analyzed, 4311 patients met inclusion criteria. Of these, only 507 (11.8%) patients had surgical nutritional access (gastrostomy or jejunostomy) (group I), while 3804 patients (88.2%) did not (group II). In the propensity score-matched population, there were 482 patients in each group. The patients in group I had lower odds of mortality and postoperative gastrointestinal complications (paralytic ileus, anastomotic dehiscence, and intestinal fistulae) ( P-value <.01, respectively).

Discussion

Elderly who receive surgical nutritional access have lower rates of gastrointestinal complications and mortality.
Initial Surgical Treatment for Breast Cancer and the Distance Traveled for Care
Authors: Kirkpatrick Daniel R. , Markov Nickolay P. , Fox Justin P. , Tuttle Rebecca M.
Published: December 2020

Background

Geography may influence the operative decision-making in breast cancer treatment. This study evaluates the relationship between distance to treating facility and the initial breast cancer surgery selected, identifying the characteristics of women who travel for surgery.

Methods

Utilizing Florida state inpatient and ambulatory surgery databases, we identified female breast cancer patients who underwent surgical treatment from January 1 to December 31, 2013. Patients were subgrouped by distance to treatment facility. The primary outcome was the initial surgical treatment choice. Regression models were used to identify factors associated with greater distance to initial treatment.

Results

The final sample included 12 786 patients who underwent lumpectomy, mastectomy alone, or mastectomy with reconstruction. Compared to women who traveled < 4.0 miles, women who traveled > 14.0 miles were younger ( P < .001), more often identified as white with private insurance ( P < .001) and were less likely to have three or more medical comorbidities ( P < .001). With increased travel to treatment, the frequency of lumpectomy decreased ( P < .001), while the frequency of mastectomy with reconstruction increased ( P < .001). Increasing age in years (adjusted odds ratio (AOR) = .98 [95% CI = .98-.99]) and identifying as nonwhite with private (AOR = .70 [.61-.80]) or public insurance (AOR = .64 [.56-.73]) was associated with less frequently travelling for initial breast cancer surgery.

Discussion

The relationship between the initial surgical treatment for breast cancer and the distance traveled for care highlights a disparity between those who can and cannot travel for treatment.
A Review of “Prehospital Hypotension as a Valid Indicator of Trauma Team Activation” (2000)
Authors: Franklin Glen A.
Published: December 2020

Prehospital hypotension has been utilized for decades as a surrogate marker of injury severity. Several studies have discussed the correlation between injury and hypotension both in the field as well as in the emergency department. Increases have been noted in injury severity score and mortality. Resource utilization is higher in this patient population. This study revisits our original work from 2000 and reviews the current literature regarding hypotension and injury severity. We also examine the role of prehospital hypotension as an indicator of trauma team activation and resource allocation. This review serves as a part of a Literary Festschrift in honor of Dr J David Richardson’s role as the Editor-in-Chief of The American Surgeon.
Missions, Humanitarianism, and the Evolution of Modern Global Surgery
Authors: Ellis Danielle I. , Nakayama Don K. , Fitzgerald Tamara N.
Published: December 2020

Modern global surgery, which aims to provide improved and equitable surgical care worldwide, is a product of centuries of international care initiatives, some borne out of religious traditions, dating back to the first millennium. The first hospitals ( xenodochia) were established in the 4th and 5th centuries CE by the early Christian church. Early “missions,” a term introduced by Jesuit Christians in the 16th century to refer to the institutionalized expansion of faith, included medical care. Formalized Muslim humanitarian medical care was marked by organizations like the Aga Khan Foundation and the Islamic Association of North America in the 20th century. Secular medical humanitarian programs developed in the 19th century, notably with the creation of the International Committee of the Red Cross (1863) and the League of Nations Health Organization (1920) (which later became the World Health Organization [1946]). World War II catalyzed another proliferation of nongovernmental organizations, epitomized by the quintessential humanitarian health provider, Médecins Sans Frontières (1971). “Global health” as an academic endeavor encompassing education, service, and research began as an outgrowth of departments of tropical medicine and international health. The American College of Surgeons brought a surgical focus to global health beginning in the 1980s. Providing medical care in distant countries has a long tradition that parallels broad themes in history: faith, imperialism, humanitarianism, education, and service. Surgery as a focus of academic global health is a recent development that continues to gain traction.
Clinical Characteristics Associated With Higher Enoxaparin Dosing Requirements for Venous Thromboembolism Prophylaxis in Trauma Patients
Authors: Hashim Yassar M. , Dhillon Navpreet K. , Veatch Jessica M. , Barmparas Galinos , Ley Eric J.
Published: December 2020

Introduction

Enoxaparin dosed by an anti-Xa trough level is effective at reducing venous thromboembolism (VTE) in trauma patients. We identified the patient characteristics associated with higher enoxaparin dosing based on anti-Xa trough levels.

Methods

A retrospective review was conducted on trauma patients admitted between August 2014 and February 2018 who received enoxaparin dosed by the anti-Xa trough level. Patients who received enoxaparin < 50 mg every 12 hours were compared to those who required ≥ 50 mg every 12 hours.

Results

Of the 246 patients included, 32 (13.0%) required enoxaparin ≥ 50 mg every 12 hours to achieve the prophylactic trough level. Factors associated with a higher dose of enoxaparin were male (96.8% vs. 3.2%, P < .01), younger age (39.5 vs. 52.7 years, P < .01), higher creatinine clearance (CrCl) (125.9 vs. 93.7 mL/min, P < .01), higher body surface area (2 m2 vs. 1.8 m2, P < .01), and higher injury severity score (18.4 vs. 10.8, P < .01). Height, weight, and body mass index were not significant factors. On regression analysis, CrCl was the only independent predictor for higher enoxaparin dose. There was an increased deep venous thrombosis rate in the higher dose cohort (12.5% vs. 0, P < .01) but no significant differences in transfusion rates.

Conclusion

Trauma patients who require higher enoxaparin doses to achieve prophylactic anti-Xa trough levels have a higher CrCl. Patients with high CrCl may benefit from an initial higher dose of enoxaparin to achieve a target anti-Xa level in a shorter time interval to decrease VTE risk.
Sleeve Gastrectomy as a Novel Procedure for Gastroparesis
Authors: Alicuben Evan T. , Samaan Jamil S. , Houghton Caitlin C. , Soffer Edy , Lipham John C. , Samakar Kamran
Published: December 2020

Background

Laparoscopic sleeve gastrectomy (LSG) has recently been considered for the surgical management of refractory gastroparesis. Our study aims to determine the efficacy of LSG as a new treatment modality for gastroparesis.

Methods

A multi-surgeon single institution retrospective chart review of patients who underwent LSG for refractory gastroparesis from September 2016-December 2017. Pre- and postoperative Patient Assessment of Upper Gastrointestinal Disorders-Symptoms Severity Index and/or Gastroparesis Cardinal Symptom Index (GCSI) questionnaires were reviewed. A telephone survey was conducted. Statistical analysis consisted of two-sample t test and utilized SAS v9.4. A P-value <.05 was considered significant.

Results

There were 10 patients included and 80% were women with an average age of 43 years (24-63). Mean Body Mass Index was 24.5 (16.8-39.6), and median gastric emptying at 4 hours was 50% (30-85). Etiology of gastroparesis was 50% idiopathic, 40% diabetic, and 10% postsurgical. 80% of patients had previously undergone gastric electrical stimulator implantation, 20% pyloric botox injections, and 1 patient jejunostomy tube placement. One patient required conversion from laparoscopic to open secondary to adhesions. Median length of stay was 5 days (2-13), and median follow-up was 13.3 months. 90% of patients were tolerating a regular diet at longest follow-up with significant improvement in self-reported symptoms. GCSI scores were 33.6 preoperatively and 14.9 postoperatively ( P = .01).

Discussion

Our study adds to the literature examining the role of LSG in the treatment of gastroparesis. LSG has favorable outcomes at short-term follow-up for patients with refractory gastroparesis.
Factors that Predict the Need for Subtotal Cholecystectomy
Authors: Tang Annie , Cohan Caitlin M. , Beattie Genna , Mooney Colin M. , Chiang Anna , Keeley Jessica A.
Published: December 2020

Background

Subtotal cholecystectomy is a “damage control” or “bailout procedure” that is used in difficult gallbladder cases when severe inflammation distorts the local anatomy resulting in increased risk in damage to surrounding structures. Subtotal cholecystectomy rates increased nationally over the past decade. We aimed to determine provider experience and patient factors associated with the performance of subtotal cholecystectomies.

Methods

All cholecystectomies from 2016 to 2019 were reviewed. Patient demographics, laboratory values, imaging, preoperative diagnosis, surgical technique (fenestrating vs. reconstituting), and years of attending and resident experience were collected. Multivariable regression analysis was performed to evaluate for factors that increase the likelihood of subtotal cholecystectomy.

Results

Of 916 cholecystectomies, 86 were subtotal. The likelihood of subtotal cholecystectomy did not increase based on attending experience of ≤5 vs. > 5 years (odds ratio (OR) .66, P = .09). Older age (adjusted odds ratio (aOR) 1.23, P = .03), male sex (aOR 2.59, P < .01), white blood cells (WBC) above 10.3 (aOR 2.02, P = .02), and preoperative diagnosis of acute on chronic cholecystitis (aOR 5.47, P < .01) were associated with increased likelihood of subtotal cholecystectomy.

Discussion

Older age, male sex, WBC above 10.3, and preoperative diagnosis of acute on chronic cholecystitis were associated with the increased likelihood of subtotal cholecystectomies. The performance of subtotal cholecystectomy was not impacted by attending years of experience. In cases of severe gallbladder pathology, this technique is being used as an operative strategy among all surgeon levels.