bluuebunny/crossref_metadata_2025 huggingface dataset:
High-Risk Colorectal Surgery: What Are the Outcomes for Geriatric Patients?
Authors: Dworsky Jill Q. , Childers Christopher P. , Maggard-Gibbons Melinda , Russell Marcia M.
Published: June 2020

The population is aging and more geriatric patients are undergoing surgery. The national burden and age-specific outcomes of previously defined high-risk colorectal procedures (HRCP) remain unknown. Using the 2014 National Inpatient Sample, patients were stratified into nongeriatric (NG, <65 years), younger geriatric (YG, 65–79 years), and older geriatric (OG, ≥80 years) cohorts. Cases were grouped into nonelective admissions (NA) and elective admissions (EA). Nationally representative outcomes were compared across age group and admission type. Of 215,425 patients undergoing HRCP, 47.3 per cent were ≥65 years. During NA and EA, inpatient mortality, discharge to nursing facility, and median postoperative length of stay increased with each increasing age category ( P < 0.001). Outcomes during NA were worse than EA in all age groups ( P < 0.001). For example, rates of discharge to nursing facility were 13.4 per cent NG, 39.4 per cent YG, and 64.7 per cent OG during; NA and 3.1 per cent NG, 13.3 per cent YG, and 34 per cent OG during EA. During NA and EA, cost was equal in YG and OG but greater than in NG. Outcomes after HRCP are worse for older patients and for nonelective cases. This information can inform preoperative counseling and targeted quality improvement projects. Further work is needed to understand geriatric-specific risk factors and outcomes to provide high-quality patient-centered care.
Practice Changes in Postoperative Feeding after Elective Colorectal Surgery: From Prospective Randomized Study to Everyday Practice
Authors: Chough Ino , Zaghiyan Karen , Ovsepyan Gayane , Fleshner Phillip
Published: June 2020

Early postoperative feeding is the standard of care after colorectal surgery and is associated with improved outcomes. A controlled study performed at our center demonstrated faster bowel function recovery and shorter hospital stay without an increase in postoperative morbidity for a solid versus clear-liquid diet on postoperative day (POD) 1 after colorectal surgery. The present study aims to evaluate the impact of these findings on the practice of diet advancement by board-certified general surgeons (GS) and colorectal surgeons (CRS) at an urban teaching hospital. Patients undergoing elective colorectal surgery were prospectively evaluated. Data were compared with that of a study cohort that underwent elective colorectal surgery reported in 2012. Early postoperative feeding in the more recent cohort statistically increased for all cases on POD 0 and POD 1. Diet advancement over time revealed significant changes in early feeding on POD 0 for patients operated on by CRS (0% vs 83%; P < 0.0001) but not GS (13% vs 13%; P = 1). Patients operated on by either CRS or GS and offered early feeding on POD 1 did not significantly differ between time periods. Despite well-documented evidence of the advantages of early feeding, GS, but not CRS, remain reluctant to administer early diets to patients after colorectal surgery.
Monitoring Complications of Medically Managed Acute Appendicitis
Authors: Siletz Anaar , Grotts Jonathan , Lewis Catherine , Tillou Areti , Cheaito Ali , Cryer Henry
Published: June 2020

Nonoperative management of acute appendicitis is becoming widespread, but recurrence and the potential for a complicated course are important concerns. An admission report-based institutional database was created to monitor appendicitis treatment outcomes. Complications and complexity of surgery were recorded based on manual chart review. A cohort of patients spanning one year was analyzed. Initial management was operative in 181 (82%) and nonoperative in 39 (18%) cases. There were no differences in demographics, BMI, or Alvarado score. One operative patient and 17 non-operative patients required additional treatment for recurrence/nonresolution (0.6% vs 44%, P < 0.00001). Twenty-eight (15%) operative patients and 17 (44%) nonoperative patients had complications ( P = 0.0003). Thirty-six (19.9%) operations in the operative group and 8 (53.3%) in the non-operative group were classified as complex ( P = 0.007). Hospital stay was longer in the nonoperative group (one vs two days, P = 0.005). Two incidental malignancies in the operative group and one in the nonoperative group were identified. These results are consistent with prior studies showing that recurrence/nonresolution is common after nonoperative management. For patients with recurrence/nonresolution, surgery may be more complex.
Results from a Quality Improvement Project to Decrease Infection-Related Ventilator Events in Trauma Patients at a Community Teaching Hospital
Authors: Anand Tanya , Ponce Santa , Pakula Andrea , Norville Cindy , Kallish David , Martin Maureen , Skinner Ruby
Published: June 2020

Ventilator-associated pneumonia (VAP) is linked to increased morbidity and mortality and clinical protocols (VAP bundles) have evolved to minimize VAP. In 2009, a quality improvement project was implemented at our institution to decrease VAP rates in adult trauma patients. AVAP prevention committee was developed, and formal evidence-based education for the nursing and physician staff was introduced. During the study period (2009–2016), 2380 patients required ICU admission to our Level II trauma center. The mean Injury Severity Score was 33 1 12, and there were 17 per cent penetrating and 83 per cent blunt injuries. The early compliance (2010) with the VAP bundle was 65 per cent. Within one year of the implementation of VAP prevention, the compliance increased to >90 per cent. Compliance has been carefully trended and has remained at 100 per cent. All of the aforementioned interventions have resulted in a sustained dramatic decline in VAP, from 12 per cent in 2009 to 0 per cent in 2016. Ongoing education and ICU policy development has become the mainstay of our trauma ICU program. The introduction of evidence-based care education imparted a culture of excellence resulting in favorable outcomes in high-risk trauma patients related to VAP prevention. Ongoing monitoring and education is required to sustain these promising outcomes.
Demonstrating Higher Incidence of Advanced Breast Malignancies in Our Young Hispanic Population
Authors: Klein Amanda , Villareal Michael , Radpour Sepeadeh , Goodgame Boone , Ali Sadia , Clark Adam , Uecker John
Published: June 2020

Historically, the Hispanic population in the United States has had a lower incidence of cancer than the matched non-Hispanic population, despite disparities in access to health care, screening, and prevention. Our experience in Austin, Texas, directly contradicts this. We have seen a disproportionate amount of young Hispanic patients with advanced malignancies, particularly of the breast. The aim of this study was to compare the incidence of advanced breast malignancies. We performed a retrospective review over a 10-year period (2003–2013) of all newly diagnosed breast cancer patients. Data were collected from the cancer registry. Patients were divided into two groups: Hispanic versus non-Hispanic descent, with a subgroup of those aged less than 50 years. Primary outcome was the incidence of advanced cancers (stage 3 or 4). There were a total of 3968 breast cancer patients seen in our Shivers Cancer Center from 2003 to 2013, with an overall incidence of advanced breast cancer of 11.5 per cent. Of the patients aged less than 50 years, 14.2 per cent had advanced breast cancer. However, the rate among Hispanic patients was 21.3 per cent, whereas in non-Hispanic patients it was 13.5 per cent, P = 0.002. Being Hispanic was found to be an independent predictor of having advanced malignancies at a young age (odds ratio 1.7, confidence interval 1.1–2.5, P = 0.01). Here in Austin, Texas, we have found a higher overall incidence of breast cancer among young Hispanic women. This is important to recognize because more efforts may be required to increase screening and health-care access to this population.
Association of Thoracic Epidural Pain Management with Urinary Retention after Complex Abdominal Wall Reconstruction
Authors: Haskins Ivy N. , Ilie Ramona N. , Krpata David M. , Perez Arielle J. , Butler Robert S. , Prabhu Ajita S. , Rosenblatt Steven , Rosen Michael J.
Published: June 2020

The association of thoracic epidural analgesia and urinary retention after complex abdominal wall reconstruction (CAWR) is unknown. The purpose of this study was to investigate the association between the presence of a thoracic epidural, timing of Foley catheter removal, and the rates of urinary retention and catheter-associated urinary tract infections (CAUTIs) in patients undergoing CAWR. All patients undergoing CAWR, who had an epidural catheter for postoperative pain management at our institution from September 2015 through April 2016, were prospectively followed. Patients were divided into two groups. Group 1 had their Foley catheters removed on postoperative day one, whereas Group 2 had their Foley catheters removed after epidural removal. The incidence of urinary retention and CAUTI were compared between the two groups. A total of 67 patients met inclusion criteria; 27 (40.3%) patients were in Group 1. Patients in Group 1 were significantly more likely to experience urinary retention requiring Foley catheter replacement ( P = 0.02). There was no statistically significant difference in the rate of CAUTI between the two groups ( P = 0.51). Patients undergoing CAWR with thoracic epidural pain management are at risk of experiencing postoperative urinary retention. Foley catheter removal after epidural removal does not place the patient at an increased risk for CAUTI and therefore should be strongly considered in this patient population.
Patient's Privacy Violation on Social Media in the Surgical Area
Authors: Silva Diego Adão Fanti , Colleoni Ramiro
Published: June 2020

In the new era of mobile technologies and social media, patient's privacy is at risk. Surgical patients have high visual appeal and may be vulnerable because a significant proportion of cases consist of emergency and trauma, in which patients are frequently unconscious. This study aims to identify the most vulnerable health providers to share patient's confidential data on social media in the surgical environment and their awareness of the confidentiality rules and laws. We surveyed medical graduates, surgical residents, and attending surgeons from a quaternary university hospital. Demographic data, usage and frequency of mobile apparatus, social media access, patient's data dissemination, and knowledge of laws and rules governing patient's privacy were recorded. One hundred fifty-six individuals (52 graduates, 51 residents, and 53 attending surgeons; mean age 24, 28, and 59 years, respectively) participated in the study. Patient's information was shared on social media by 53 per cent of the graduates, 86 per cent of the residents, and 32 per cent of the attending surgeons ( P < 0.05). Confidentiality preservation policies were unknown to 69 per cent of graduates, 80 per cent of residents, and 62 per cent of attending surgeons ( P = 0.124). Awareness of protocols to guide health-care professionals about safer use of social media was 0 per cent for graduates, 15 per cent for residents, and 22 per cent for attending surgeons ( P = 0.002). Residents were the most vulnerable to share patient's information on social media compared with graduates and attending surgeons. Health institutions should promote continuing education in medical ethics, focussing on residents.
Is Obesity Protective in Thoracoabdominal Penetrating Trauma?
Authors: Nash Nick , Kimbrough Charles W. , Mackowski Michael , Benns Matthew V. , Smith Jason W. , Harbrecht Brian G. , Bozeman Matthew
Published: June 2020

The incidence of obesity has been increasing in the United States, and the medical care of obese patients after injury is complex. Obesity has been linked to increased morbidity after blunt trauma. Whether increased girth protects abdominal organs from penetrating injury or complicates management from obesity-associated medical comorbidities after penetrating injury has not been well defined. All patients admitted with penetrating injury between January 1, 2010, and December 31, 2013, at a university-affiliated Level I center trauma center were reviewed. Primary endpoints for analysis were the presence of significant injuries requiring operative intervention and outcomes, including inpatient complications. Logistic regression, chi-squared tests, and the Kruskal-Wallis test were used to compare groups. Five hundred patients were included in the study; 225 with stabs and 275 with gunshot wounds (GSWs). In each group, there was no major difference between obese and nonobese patients in regard to injury location, operative approach, or postoperative outcomes. Unadjusted odds ratios comparing both overweight and obese individuals to normal BMI patients did not suggest a decreased rate of therapeutic operations for either population after stabs or GSWs. In obese or overweight patients, there is no difference in the rate of operative intervention for significant injuries after penetrating axial trauma compared with a normal BMI population. On the other hand, obesity was not associated with prolonged length of stay, increased complications, or death after penetrating injuries.
Investigating Clinical and Cost Burdens of Law Enforcement–Related K9 Injuries: The Impact of “the Bite” on a Community Hospital
Authors: Coombs Andre V. , Eyerly-Webb Stephanie A. , Solomon Rachele J. , Sanchez Rafael , Lee Seong K. , Carrillo Eddy H. , Kiffin Chauniqua , Rosenthal Andrew A. , Whitehouse Jill , Germain Barbara , Davare Dafney L.
Published: June 2020

The decision to introduce canines (K9s) to a law enforcement (LE) agency does not typically involve the evaluation of the fiscal or clinical impact on local hospitals. This study compared injury, cost, and care associated with K9s to a common nonlethal force method, the Thomas A Swift Electrical Rifle (TASER), to highlight the cost and resources required to treat both patient types. Patients treated for LE-related K9 and TASER injuries at a Level I community-based trauma center (2011–2016) were evaluated for level of care required (e.g., surgeon/specialist), clinical interventions, proxy medical costs, and length of stay (LOS). Nearly one-third of K9 patients required tertiary-level medical care. The cost of treating the K9-inflicted injuries (n = 75) was almost twice as costly as care for patients subdued with a TASER (n = 80); the K9 patients had significantly (one-tailed t tests) higher medical costs (P = 0.036), required more medical procedures (P = 0.014), and had longer LOS (P = 0.0046) than the TASER patients. Patients with K9 injuries had higher acuity and were significantly more expensive to treat with longer LOS than TASER injuries. LE agencies considering establishing and operating a K9 unit should initiate discussions with their local medical first responders and health-care facilities regarding the capabilities to treat severe K9 injuries to ensure adequate resource allocation.
Drainage versus No Drainage after Laparoscopic Cholecystectomy for Acute Cholecystitis: A Meta-Analysis
Authors: Xu Ming , Tao You-Liang
Published: June 2020

To conduct a randomized controlled trial (RCT), meta-analysis to assess the effectiveness of drains in reducing complications after laparoscopic cholecystectomy (LC) for acute cholecystitis needs to be carried out. An electronic search of PubMed, Embase, Science Citation Index, and the Cochrane Library from January 1990 to January 2018 was performed to identify randomized clinical trials that compare prophylactic drainage with no drainage in LC for acute cholecystitis. The outcomes were calculated as odds ratios (ORs) with 95 per cent confidence intervals (CIs) using RevMan 5.2. Four RCTs, which included 796 patients, were identified for analysis in our study. There was no statistically significant difference in the rate of morbidities (OR = 1.23, 95% CI 0.55–2.76, P = 0.61). Abdominal pain was more severe in the drain group 24 hours after surgery (mean difference = 0.80, 95% CI 0.47–1.14; P < 0.00001). No significant difference was present with respect to wound infection rate and hospital stay. The use of abdominal drainage does not appear to be of any benefit in patients having undergone early LC for acute cholecystitis.
Barriers to Colonoscopy in an Uninsured Patient Population—A Quality Improvement Project
Authors: Wagner Maxwell S. , Burgess Jessica , Britt Rebecca C.
Published: June 2020

Colorectal cancer remains common, with the “80 per cent by 2018” initiative proposed by the National Colorectal Cancer Roundtable. This study was designed to examine obstacles for patients who did not receive their scheduled colonoscopy, focusing on the impact of insurance status. Retrospective chart review was carried out on patients who did not complete their colonoscopy as scheduled from January 2013 to June 2017. The control group consisted of patients who completed their scheduled colonoscopy. One hundred and seventy five patients missed 200 colonoscopies. The most common reasons for cancellation were patient illness (16%), no-show (14%), no prep carried out (13%), inadequate prep (10%), and no transportation (11%). The canceled patients were significantly more likely to have the combination of no insurance and no Primary Care Provider (PCP) (13% vs 4%, P = 0.008), personal history of cancer (22% vs 12%, P = 0.02), and higher rates of prior GI issues (78% vs 50%, P < 0.001). The canceled group had a significantly lower history of colon polyps (37% vs 53%, P = 0.006). Difficulty with the bowel prep in addition to lack of insurance and poverty likely does create a barrier, even in a system that has a safety net, atop other issues such as transportation and inability to miss work playing a role.
The Ochsner Legacy
Authors: Nakayama Don K.
Published: June 2020

One of the iconic families in American surgery is the Ochsners. The youngest son of Swiss immigrants, Henry Ochsner (1877–1902) was the first to enter the medical profession. His promising internship at the Johns Hopkins Hospital ended when he died of cholera, a tragedy deeply felt by his mentor William Osler. On another branch of the family tree, Albert Ochsner (1858–1925) wrote authoritative textbooks on surgery and became president of the ACS and the American Surgical Association. His most significant achievement may have been his mentorship of his cousin's son Alton (1896–1981), guiding his medical education and training in surgery. The younger Ochsner succeeded Rudolph Matas as chair of surgery at Tulane University at the age of only 31 years. Under his leadership, Charity Hospital in New Orleans became a leading program for surgical training and Tulane earned a reputation for clinical excellence. Ochsner and four partners from the Tulane faculty created a multidisciplinary clinic to attract patients from a wider area, a facility that would become today's Ochsner Clinic. His son John (1927–2018) followed him in the profession and received specialty training in cardiovascular surgery under Michael DeBakey in Houston, a Tulane graduate and an Ochsner trainee. John Ochsner returned to the Ochsner Clinic to establish a major cardiothoracic and vascular surgery program. Further generations of the Ochsner family continued the family legacy in surgery and medicine, exemplified by M. Gage Ochsner (1954–2013), Alton's grandson and John's nephew, who became a leading traumatologist and surgical educator in Savannah.
Longer Operative Time and Intraoperative Blood Transfusion are Associated with Postoperative Anastomotic Leak after Lower Gastrointestinal Surgery
Authors: Cortina Chandler S. , Alex Gillian C. , Vercillo Kristin N. , Fleetwood Vidyaratna A. , Smolevitz Jill B. , Poirier Jennifer , Myers Jonathan A. , Orkin Bruce A. , Singer Marc A.
Published: June 2020

Anastomotic leak after lower gastrointestinal surgery is a complication with potential for high morbidity, mortality, and increased costs. A single-institution retrospective chart review was performed on all patients who underwent lower gastrointestinal surgery between June 2009 and June 2013. Fifty-seven variables were included in our analysis and their association with postoperative anastomotic leak was examined. Nine hundred fifty-two patients underwent 983 lower gastrointestinal anastomoses with an overall leak rate in this series of 6 per cent. Type of intestinal anastomosis created (P < 0.00005), operative indication (P < 0.015), operation performed (P < 0.014), intraoperative blood transfusion (P < 0.017), and intraoperative surgical drain placement (P < 0.022) were all predictive of anastomotic leak. Anastomotic leak rate increased by 1.3 times for every additional hour in the operating room after three hours. Both increasing operation time and intraoperative blood transfusions were associated with an increased rate of anastomotic leak. When operative time extends beyond three hours or in those cases were blood transfusions are given, surgeons should consider taking steps to minimize the risks of a potential anastomotic leak.
Meta-Analysis of Post-Intubation Hypotension: A Plea to Consider Circulation First in Hypovolemic Patients
Authors: Ferrada Paula , Manzano-Nunez Ramiro , Lopez-Castilla Valeria , Orlas Claudia , GarcÍA Alberto F. , Ordonez Carlos A. , Dubose Joseph J.
Published: June 2020

Hypovolemic patients can develop postintubation hypotension (PIH). Our objective is to review the literature regarding PIH and the association with mortality. We searched MEDLINE from inception to February 2018. A meta-analysis was performed to assess the effect of PIH on mortality. The results of the meta-analysis were reported in forest plots of the estimated effects of the included studies with a 95 per cent confidence interval. Heterogeneity was evaluated using the I2 test, which corresponded to low (I2 < 25%), medium (I2 = 25–75%), and high (I2 > 75%) heterogeneity. We identified 243 records. Four studies were included in the meta-analysis. The studies reported 2044 patients with 36.8 per cent (n = 753) developing PIH. Data indirectly reflecting the hemodynamic status were available in three studies (n = 1117 patients). Overall mortality was 24.6 per cent (n = 503) and was significantly higher in patients that developed PIH [mortality, n (%): PIH = 250/753 (33.2%) vs 253/1291 (19.6%), P < 0.001]. Patients that develop PIH have an increased mortality. Considering a targeted resuscitation in hypovolemic patients is pivotal to minimize PIH.
Multidisciplinary Patient Management Improves Mortality in Geriatric Trauma Patients
Authors: Losh Joseph , Duncan Thomas K. , Diaz Graal , Lee Hyesun , Romero Javier
Published: June 2020

Improvement in the care of the traumatically injured patient should be a goal at all trauma centers. One purpose of the data generated by the Trauma Quality Improvement Program is to provide insight which will lead to quality improvement initiatives and to promote intrinsic improvement on a center by center basis. The primary objective of this study was to measure the efficacy of instituting a multidisciplinary Trauma Medicine (T-MED) program to improve geriatric mortality at Ventura County Medical Center (VCMC). Trauma Quality Improvement Program data at VCMC before October 2013 demonstrated poor performance in treating geriatric patients. To attempt to improve outcomes, a multidisciplinary T-MED program was instituted in October 2013, which included a mandatory consultation and collaborative management with hospitalist medicine physicians for all trauma patients 65 years of age or older. The T-MED program increased focus on preexisting conditions, medication management, and discharge planning, including rehabilitation and continuity of care. Institution of a T-MED program at VCMC resulted in significant improvement in mortality rates for geriatric trauma patients.
Diagnosis-Related Group in Colon Surgery: Identifying Areas of Improvement to Drive High-Value Care
Authors: Hughes Byron D. , Moore Samantha A. , Mehta Hemalkumar B. , Shan Yong , Senagore Anthony J.
Published: June 2020

Diagnosis-related group (DRG) migration is defined as the reassignment of colectomy patients from DRG 331 to 330 based exclusively on postoperative complications. Strategic and comparative application of this metric has the potential to demonstrate baseline and excessive rates of complications related directly to patient care differences across institutions. The aim of this study was to report the variability of DRG migration across United States hospitals and its impact on overall cost and length of stay (LOS). This study investigated the variability of DRG migration rates across United States hospitals polling 5 per cent of the national Medicare data. The study end-points were total cost, LOS, and DRG migration rate. Hospitals were classified into tertiles for low (0.1–16.6%), moderate (16.7–23.0%), and high (23.1–83.3%) DRG migration rates. The study included 5120 patients from 615 hospitals. DRG migration rates for hospitals ranged from 0.1 per cent to 83.3 per cent, with 157 in the low, 183 in the moderate, and 364 in the high tertile. DRG migration resulted in a progressively increased LOS and hospital costs from the lowest to highest tertile. Several diagnoses were identified which are suggestive of failure to integrate evidence-based processes of care across the tertiles. The data confirm a wide variation in DRG migration rates from DRG 331 to 330 based only on postoperative complications. These ranges allow for the potential definition of both best practice, and opportunities for quality improvement with respect to postoperative complications, identification of hospital outliers, and the economics of care as part of a value-based care program.
Epidemiology of Traumatic Esophageal Injury: An Analysis of the National Trauma Data Bank
Authors: Xu Alexander A. , Breeze Janis L. , Paulus Jessica K. , Bugaev Nikolay
Published: June 2020

Existing literature on traumatic injury of the esophagus (TIE) is limited. We aimed to describe the clinical characteristics and outcomes of TIE. We reviewed the National Trauma Data Bank for the years 2010–2015. We described the demographics, characteristics, and outcomes of adult (age ≥16 years) TIE patients and also compared those factors in blunt versus penetrating TIE. The association between TIE and mortality was analyzed using multivariable logistic regression. Thousand four hundred eleven adult TIE patients were identified (37 per 100,000 trauma patients, 95% confidence intervals (CI): 35, 39). TIE patients were younger (38 vs 52 years), more likely to be male (81% vs 62%), and more severely injured (Injury Severity Score ≥ 25: 45% vs 7%) than patients without TIE (all P < 0.001). TIE was observed 16 times more frequently with penetrating injuries (257 per 100,000, 95% CI: 240, 270) than with blunt injuries (16 per 100,000, 95% CI: 15, 18). Inhospital TIE mortality was 19 per cent. TIE patients had greater risk of mortality than other trauma patients, after adjusting for age, gender, and Injury Severity Score (odds ratio = 1.4, 95% CI: 1.1, 1.7). Mortality in blunt and penetrating TIE did not differ. Although extremely rare, TIE is independently associated with a marked increase in mortality, even after adjusting for other risk factors.
Orthopaedic Surgery Resident Financial Literacy: An Assessment of Knowledge in Debt, Investment, and Retirement Savings
Authors: Jennings John D. , Quinn Courtney , Ly Justin A. , Rehman Saqib
Published: June 2020

Most orthopedic residents carry significant debt and may enter their practice with little knowledge of business management, minimal retirement savings, and overall poor financial literacy. This study aimed to gauge financial literacy, debt, and retirement planning in United States orthopedic surgery residents. Willingness to participate in formalized financial education was also assessed. Eighty-five allopathic orthopedic surgery residents in the United States completed a 14-question anonymous online survey in 2016. The survey assessed demographic data, self-assessed financial knowledge, amount of credit card debt and loans, preparation for retirement, and willingness to participate in formal didactic education on these topics. Most respondents derive their financial knowledge from personal research (51%), whereas only 4 per cent have a formal curriculum. Despite most respondents reporting more than $200,000 in outstanding loans, only 31 per cent create and stick to a budget. Few programs offer retirement advice, and 48 per cent of respondents save $0 toward retirement. Eighty-five per cent of residents expressed interest in learning about personal investment, savings, and retirement planning. Orthopedic surgery residents carry significant debt and do not achieve their high-income potential until disproportionately later in life. Only 4 per cent of residents have formal training in investing, personal finance, or retirement despite a majority who desire such a curriculum. In fact, almost 75 per cent of those surveyed felt less prepared for retirement than their peers outside of medical training. This study suggests a role for formal financial education in the orthopedic curriculum to prepare residents for retirement, improve financial literacy, and enhance debt management.
Role of Double-Lumen Irrigation-Suction Tube Drainage in Severe Intra-Abdominal Infection Induced by Endoscopic Sphincterotomy– Related Perforation
Authors: Niu Dong-Guang , Huang Qian , Yang Fan , Tian Wei-Liang , Zhao Yun-Zhao
Published: June 2020

This study aimed to assess the efficacy of double-lumen irrigation-suction tube (DLIST) in treating severe intra-abdominal infection (SIAI) induced by endoscopic sphincterotomy–related perforation (EST-rP). We enrolled 34 consecutive patients who had been transferred to our hospital with SIAI induced by EST-rP from January 2000 to June 2018. Then they were assigned into two groups based on whether or not rescue surgery had been performed: failed nonoperative treatment group (n = 9) and failed rescue surgery treatment group (n = 25). All 34 patients received DLIST for positive draining by surgery in our hospital. Data collection included demographics, indication for endoscopic retrograde cholangiopancreatography, time to rescue surgery, surgical procedure, surgical success rate, complications, hospital stay, and postoperative outcome. The research enrolled 34 patients (ages 27–79 years, mean of 57.8 ± 12.1 years). There were no significant differences in age and gender between two groups ( P > 0.05). After being admitted, they were diagnosed with sepsis induced by SIAI (Sequential Organ Failure Assessment score range of 2–6, mean of 3.6 ± 0.95). The time from endoscopic retrograde cholangiopancreatography to rescue surgery was 12 to 336 hours (mean of 73.7 ± 72.2 hours); overall hospital stay was 15 to 405 (mean of 127.5 ± 81.5) days. The hospital stay was significantly longer in the failed rescue surgery group than that of the failed nonoperative treatment group ( P < 0.05). The overall mortality rate was 11.8 per cent (4/34). The mortality rate was 16 per cent (4/25) and 0 per cent (0/9), respectively. As a modified suction technology, DLIST placement can effectively treat SIAI induced by EST-rP and lower the mortality rate of rescue surgery treatment.
Blunt Adrenal Injury: Results of a State Trauma Registry Review
Authors: Digiacomo Jody C. , Gerber Noam , Angus L. D. George , Munnangi Swapna , Cardozo-Stolberg Sara
Published: June 2020

In the past, injuries to the adrenal glands due to blunt trauma were considered rare, and were reported to be associated with high Injury Severity Scores (ISSs) and high mortality. Recent reports have reported a much high incidence associated with lower ISS and lower mortality. The purpose of this study was to assess the incidence of adrenal gland injuries due to blunt trauma in a large state trauma registry and determine whether these injuries are associated with a higher ISS and increased risk for mortality. A retrospective review was performed on the New York State Trauma Registry comparing blunt injured adults with adrenal injuries to those who did not. Concurrent organ injuries, ISS, and inhospital mortality were compared. Three hundred thirty-nine patients with adrenal gland injuries were identified. Concurrent liver and kidney injuries were more prevalent in the adrenal injured group, and concurrent injuries to the small and large intestine and spleen were more prevalent in the nonadrenal injured group. There was no difference in ISS or mortality between the adrenal injured and nonadrenal injured populations. The results of this study are consistent with recent smaller studies which identified incidence rates which were higher than previously reported and that ISS and mortality risk were unchanged by the presence of blunt adrenal gland injuries. Adrenal gland injuries due to blunt trauma are not uncommon, with an incidence rate of 0.61 per cent. Adrenal gland injuries are not associated with higher ISS or an increased risk of mortality.
Use of the Alvarado Score in Elderly Patients with Complicated and Uncomplicated Appendicitis
Authors: Deiters Alyssa , Drozd Andrew , Parikh Priti , Markert Ronald , Shim Joon K.
Published: June 2020

The purpose of this study was to determine whether the Alvarado score is beneficial in identifying complicated versus uncomplicated acute appendicitis in elderly patients. A retrospective review was conducted of patients aged 65 years and older who underwent an appendectomy for pathologically confirmed appendicitis. A review of 310 operative reports and patient charts from October 2012 to December 2016 yielded 216 patients. Patients were grouped based on complicated versus uncomplicated appendicitis. One hundred ten patients had complicated appendicitis, whereas 106 patients were uncomplicated. Among the complicated appendicitis patients, 76.4 per cent were perforated, 38.2 per cent were gangrenous, and 34.5 per cent had an abscess. The complicated appendicitis group had a higher mean duration of symptoms (2.70 ± 3.41 days vs 2.09 ± 3.08 days, P = 0.011). Appendectomies that were open or converted to open were more likely to be associated with complicated appendicitis (75% vs 48%, P = 0.012). Mean hospital length of stay was greater in those with complicated appendicitis (5.34 ± 5.56 days vs 3.12 ± 2.86 days, P < 0.001). The two groups did not differ on mean Alvarado score (complicated = 6.96 ± 1.99 vs uncomplicated = 6.72 ± 1.85, P = 0.36). Only 62.5 per cent of patients had an Alvarado score that met the cutoff for acute appendicitis. The Alvarado score was not able to differentiate complicated from uncomplicated appendicitis in elderly patients.
Preoperative Chemotherapy and Resection Margin Status in Colorectal Liver Metastasis Patients: A Propensity Score–Matched Analysis
Authors: Solaini Leonardo , Gardini Andrea , Passardi Alessandro , Mirarchi Maria Teresa , D'Acapito Fabrizio , La Barba Giuliano , Cucchi Michele , Gardini Andrea Casadei , Frassineti Giovanni L. , Cucchetti Alessandro , Ercolani Giorgio
Published: June 2020

In this article, we compared the early and long-term outcomes of patients with metastatic colorectal cancer treated with chemotherapy followed by resection with those of patients undergoing surgery first, focusing our analysis on resection margin status. Patients who underwent liver resection with curative intent for colorectal liver metastases from July 2001 to January 2018 were included in the analysis. Propensity score matching was used to reduce treatment allocation bias. The cohort comprised 164 patients; 117 (71.3%) underwent liver resection first, whereas the remaining 47 (28.7%) had preoperative chemotherapy. After a 1:1 ratio of propensity score matching, 47 patients per group were evaluated. A positive resection margin was found in 13 patients in the surgery-first group (25.5%) versus 4 (8.5%) in the preoperative chemotherapy group ( P = 0.029). Postmatched logistic regression analysis showed that only preoperative chemotherapy was significantly associated with the rate of positive resection margin (odds ratio 0.24, 95% confidence interval 0.07–0.81; P = 0.022). Median follow-up was 41 months (interquartile range 8–69). Cox proportional hazard regression analysis revealed that only positive resection margin was a significant negative prognostic factor (hazard ratio 2.2, 95% CI 1.18–4.11; P = 0.014). Within the preoperative chemotherapy group, median overall survival was 40 months in R0 patients and 10 months in R1 patients ( P = 0.016). Although preoperative chemotherapy in colorectal liver metastasis patients may affect the rate of positive resection margin, its impact on survival seems to be limited. In the present study, the most important prognostic factor was the resection margin status.
Evaluation of Chest Radiographs and Laboratory Testing during Melanoma Staging Procedures
Authors: Brooks Wilson C. , Votanopoulos Konstantinos I. , Russell Gregory B. , Shen Perry , Levine Edward A.
Published: June 2020

Chest radiographs (CXRs) and laboratory testing have historically been performed as a part of low-risk melanoma (clinical stage 1/2) workup. This study evaluates the utility of routine CXRs and laboratory testing during the staging of clinical stage 1 and 2 melanoma patients. This study was approved by the Institutional Review Board at Wake Forest University. A database of sentinel lymph node biopsies performed for clinical stage 1 or 2 melanoma was used to identify early-stage melanoma patients. The medical records of patients with melanoma were reviewed and pre-operative workup procedures were recorded. Four hundred sixty-three patients were reviewed. A total of 315 patients underwent a preoperative CXR, whereas 309 received some laboratory testing. After sentinel node biopsies, 168 patients had pathologic stage 1 disease, 103 stage 2, and 44 stage 3. None of the CXRs (0%) correctly identified metastatic melanoma. Suspicious locations on CXRs and laboratory testing did not lead to metastatic findings in any patient within a year. Metastatic melanoma was not found in any patient by screening with CXRs or laboratory testing during preoperative workup. We recommend not conducting CXRs or laboratory testing during workup for surgical melanoma patients because of charges and anxiety these tests can cause. CXRs, blood tests, and metabolic panels have historically been ordered for early melanoma patients, although debate remains on their efficacy. Surgical patient records were retrospectively reviewed for these tests and no benefit was found.
The History of Surgical Staplers: A Combination of Hungarian, Russian, and American Innovation
Authors: Gaidry Alicia D. , Tremblay Laurier , Nakayama Don , Ignacio Romeo C.
Published: June 2020

Since their development in 1908, surgical staplers have been used as a method of “mechanical suturing” in efforts to divide hollow viscera and create anastomoses in an efficient and sterile manner. The concept for the surgical stapler was first developed by Humér Hultl, a Hungarian professor and surgeon, and designed by Victor Fischer, a Hungarian businessman and designer of surgical instruments. The design was highly acclaimed; however, it was bulky, cumbersome, and expensive to manufacture. In 1920, Aladár Petz, a student of Hultl, incorporated two innovations to the Fischer-Hultl stapler to create a more lightweight model, which was named the Petz clamp. In 1934, Friedrich of Ulm designed what would be the predecessor to the modern-day linear stapler. In the 1950s, Russian and American staplers began to emerge. Throughout the 1960s, a variety of stapling instruments were developed in the United States, manufactured by the United States Surgical Corporation. In the 1970s, Johnson & Johnson Ethicon brand joined the market. The United States Surgical Corporation was later bought by Tyco Healthcare and became Covidien in 2007. Through the collaboration of Felicien Steichen, Mark Ravitch, and Leon Hirsch, surgical staplers were further modified to incorporate interchangeable cartridges with various designs. With the advent of minimally invasive surgery began production of laparoscopic surgical staplers. Since its inception, the surgical stapler has provided a means to efficiently create safe and effective visceral and vascular anastomoses. The surgical stapler design continues to evolve while still maintaining the basic principles that were implemented in the original design.
Trends in Surgeon Wellness (Take a Sad Song and Make it Better): A Comparison of Surgical Residents, Fellows, and Attendings
Authors: Jackson Theresa , Morgan Jake , Jackson Diane , Cook Taylor , McLean Kevin , Agrawal Vaidehi , Taubman Kevin , Kumar Gajal , Truitt Michael S.
Published: June 2020

We aim to investigate the prevalence of posttraumatic stress disorder (PTSD), physician burnout (PBO), and work–life balance (WLB) among surgical residents, fellows, and attendings to illustrate the trends in surgeon wellness. A cross-sectional national survey of surgical residents, fellows, and attendings was conducted screening for PTSD, PBO, and WLB. The prevalence of screening positive for PTSD was more than two times that of the general population at all levels of experience, and more than half have an unhealthy WLB. The prevalence of PTSD, PBO, and unhealthy WLB declined with increasing level of experience ( P < 0.001). One deviation in this trend was a lower prevalence of PBO among surgical fellows compared with residents and attendings ( P < 0.001). Surgeon wellness improved with increasing level of experience. The incorporation of wellness programs into surgical residencies is essential to the professional development of young surgeons to cultivate healthy lasting habits for a well-balanced career and life.
What Procedures are Rural General Surgeons Performing and are They Prepared to Perform Specialty Procedures in Practice?
Authors: Stiles Roxanne , Reyes Jared , Helmer Stephen D. , Vincent Kyle B.
Published: June 2020

Rural surgeons are performing operations typically performed by “specialists.” This study describes specialty procedures performed by general surgeons operating in a rural state and how prepared the surgeons felt starting their rural practice after residency A survey was sent to all exclusively rural surgeons actively practicing in the state, inquiring about their perception of preparedness for rural practice and specialty procedures performed. The survey had a 65.2 per cent response rate. Responders felt well prepared for rural practice after residency (mean response 4.6 ± 0.8 on a Likert scale from 1 to 5; 5 = “well prepared”). Noteworthy, specialty procedures performed by rural surgeons included hysterectomies (51.2%), thyroidectomies (81.4%), para-thyroidectomies (60.5%), carotid endarterectomies (11.6%), video-assisted thoracoscopic surgery (37.2%), and lobectomies (23.3%). Prominent write-ins included nephrectomies (n = 1), ileal conduits (n = 1), open and endovascular abdominal aortic aneurysm repair (n = 1), Whipples (n = 3), and liver resections (n = 2). Rural general surgeons perform many major operations usually performed by specialists. These surgeons felt well prepared for these operations out of residency.
Interhospital Transfers with Wide Variability in Emergency General Surgery
Authors: Lauerman Margaret H. , Herrera Anthony V. , Albrecht Jennifer S. , Chen Hegang H. , Bruns Brandon R. , Tesoriero Ronald B. , Scalea Thomas M. , Diaz Jose J.
Published: June 2020

Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups: encounters not transferred, encounters transferred from a hospital, and encounters transferred to a hospital. In total, 380,405 EGS encounters were identified, including 12,153 (3.2%) encounters transferred to a hospital, 10,163 (2.7%) encounters transferred from a hospital, and 358,089 (94.1%) encounters not transferred. For individual hospitals, percentage of encounters transferred to a hospital ranged from 0 to 30.05 per cent, encounters transferred from a hospital from 0.02 to 14.62 per cent, and encounters not transferred from 69.25 to 99.95 per cent of total encounters at individual hospitals. Percentage of encounters transferred from individual hospitals was inversely correlated with annual EGS hospital volume ( P < 0.001, r = -0.59), whereas percentage of encounters transferred to individual hospitals was directly correlated with annual EGS hospital volume ( P < 0.001, r = 0.51). Individual hospital practices for interhospital transfer of EGS patients have substantial variability. This is the first study to describe individual hospital interhospital transfer practices for EGS.
National Trends in Diagnostic Imaging for Appendicitis: A Cross-Sectional Analysis Using NSQIP
Authors: Agathis Alexandra Z. , Miller Michael , Divino Celia M.
Published: June 2020

Prior studies elucidate a high predictive value of imaging to diagnose appendicitis in small, regional cohorts. This cross-sectional study uniquely analyzes diagnostic imaging in a national appendectomy population. Using the 2016 ACS NSQIP database, positive predictive values (PPVs) for CT, ultrasound (US), and MRI were evaluated using chi-squared tests. Univariate and multivariate analyses considered patient-specific factors. Imaging was performed in 94.63 per cent of 11,841 appendectomy cases; most frequently via CT (78.69%), then combination CT and US (7.52%), US (7.15%), and MRI (0.30%). CT PPV was higher in overweight (98.70%) versus underweight patients (94.85%) ( P = 0.01). Gender and age did not impact CT PPV. Imaging from a referral site did not change CTor US PPV. Our study describes imaging frequencies and confirms high PPV. We found imaging equally predictive in women of childbearing age and elderly individuals compared with the general population. Furthermore, repeat scanning is unnecessary with prior positive imaging at outside sites.
Understanding the Trauma/Acute Care Surgery Workforce
Authors: Hughes K. Michael , Ewart Zachary T. , Bell Theodore D. , Kurek Stanley J. , Swasey Krystal K.
Published: June 2020

As the roles of trauma/acute care surgeons continue to evolve, it is imperative that health-care systems adapt to meet workforce needs. Tailoring retention strategies that elicit workforce satisfaction ensure continued coverage that is mutually beneficial to surgeons and health-care systems. We sought to elicit factors related to career characteristics and expectations of the trauma/acute care surgery (ACS) workforce to assist with such future progress. In this study, 1552 Eastern Association for the Surgery of Trauma members were anonymously surveyed. Data collected included demographics, career expectations, and motivators of trauma/ACS. Four hundred eight (26%) Eastern Association for the Surgery of Trauma members responded. Respondents were 78 per cent male and had a median age of 47.3 years. Forty-six per cent of surgeons reported earning $351K–$475K and 23 per cent >$475K. At this point in their career, 49 per cent of surgeons felt quality of life was “most important”, followed by 31 per cent career ambitions and 13 per cent salary. Prominent career satisfiers were patient care and teaching. Greatest detractors were burnout, bureaucracy, and work environment. Eighty per cent would change jobs in the final 10 years of practice, 31 per cent because of family/retirement, 29 per cent because of professional growth, 24 per cent because of workload, and 7 per cent because of salary. This study could be used to help develop trauma/ACS workforce strategies. This workforce remains mobile into late career; personal happiness and patient ownership overshadow financial rewards, and most prefer a total and shared patient care model compared with no patient ownership. Burnout, bureaucracy, and work environment are dominant detractors of job satisfaction among surveyed trauma/ACS surgeons.