Journal of Surgical Research最新文献

Introduction: For lower extremity penetrating traumas (LEPT), the impact of race and insurance status, as a surrogate of socioeconomic status, is still not fully elucidated. This study aims to explore the relationship between these variables and the likelihood of receiving an amputation for LEPT to further identify disparities in trauma care.

Methods: We analyzed the 2017-2019 Trauma Quality Improvement Program databases to identify patients with LEPT. Univariate analysis of various patient factors was performed for mortality. Linear and logistic multivariate regressions were then conducted for the primary and secondary outcomes using significant variables from the univariate analysis. Finally, multivariate logistic regression identified associations between race, ethnicity, primary payor, and amputation rates.

Results: The independent factors significantly linked to amputation included Black race (odds ratio (OR) 0.745, P < 0.001), Medicare (OR 0.557, P < 0.001), Medicaid (OR 0.697, P < 0.001), and uninsured status (OR 0.661, P < 0.001). We additionally evaluated the incidence of death among the penetrating trauma victims and determined that male (OR 2.008, P < 0.001), Black (OR 1.801, P = 0.001), and uninsured patients (OR 1.910, P = 0.003) were more likely to die during admission than the privately insured.

Conclusions: Compared to privately insured victims, uninsured patients and those on Medicaid and Medicare experience lower amputation rates post-LEPT. Black patients were found to have not only a decreased likelihood of receiving an amputation following LEPT but also an increased rate of mortality during admission compared to Caucasian victims. These findings underscore the urgency to address institutional barriers hindering vulnerable populations from accessing appropriate care after trauma.

Introduction: Mounting financial pressures on academic institutions highlight the need to understand the effect on outcomes from trainee involvement in cardiac surgery. The purpose of this study is to examine the association between cardiothoracic fellows and clinical and financial outcomes in coronary artery bypass grafting (CABG).

Methods: Data for all patients from 2017 to 2022 at a single institution who underwent nonemergent, isolated, open CABG were included in the study, with patients grouped by whether there was fellow operative participation. Financial and clinical outcomes were compared between the two groups using multivariable regression and generalized estimating equations to control for variation in patient characteristics and attending cardiac surgeon practices.

Results: A total of 1997 patients met criteria for study inclusion, with 632 (31.5%) cases that had fellow participation and 1365 (68.4%) that did not. Patients in the fellow participation group had a 0.8% higher median preoperative risk score than those that did not have fellow participation. Fellow participation was associated with significantly longer total case length (61 mins) but no differences in postoperative clinical outcomes. There was an increased median total hospitalization cost of approximately $2200 in cases with fellow participation, likely attributable to increased intraoperative costs from longer case times.

Conclusions: While CT surgery fellow participation was associated with longer operative times and a small increase in hospitalization cost in CABG, there were no significant differences in clinical outcomes. Continuing to train cardiothoracic surgery fellows in this procedure is safe and would not be expected to significantly impact reimbursement under bundled payment models.

Introduction: Access to rehabilitation services after a traumatic injury improves functional outcomes. No study has examined the association between injury intent, violent versus nonviolent, and receipt of rehabilitation services after injury.

Materials and methods: We conducted a retrospective cohort study of injured adult patients admitted to our level I trauma center from January 1, 2014 to December 31, 2021. The primary exposure was violent injury, and the primary outcome was receipt of rehabilitation services upon discharge. An exploratory subgroup analysis evaluated differences in recommended disposition and the reasons for rejection from services.

Results: Among 7500 patients, 1677 (22.4%) were violently injured and 5823 (77.6%) were nonviolently injured. Patients were 45% White, 67% male, and 52% had public insurance. Adjusting for age, sex, race, ethnicity, injury severity score, insurance, and length of stay, violently injured patients were 77% less likely to receive inpatient rehabilitation (relative risk ratio 0.23 95% confidence interval [0.18, 0.30], P < 0.001) and 46% less likely to have home services (relative risk ratio 0.54, 95% confidence interval[0.43, 0.69], P < 0.001). A subgroup analysis (n = 328) demonstrated that violently injured patients were more likely to have a downgrade in discharge recommendation (27.8% versus 9.4%, P = 0.04) and more likely to have an emergency department visit within 30 d (32.0% versus 13.3%, P < 0.001).

Conclusions: Violent injury is associated with lower likelihood of receiving rehabilitation services. Subgroup analysis indicates this finding associated with facilities' selection bias, and this warrants additional study. Efforts should focus on protecting victims of violence from discrimination during the rehabilitation screening process.

Introduction: Assessing gender disparity in surgical trainees' operative opportunities and experience quantifies implicit gender bias and reflects a summation of many smaller biased interactions within the operating room environment. Highlighting gender disparity in surgery informs a platform for advocacy.

Methods: A systematic literature search was performed using Medline, Web of Science, OpenMD and Science Direct consistent with the Preferred Reporting Items for Systematic Reviews and Metanalysis guidelines. A Boolean search strategy was used to identify articles relevant to gender in operative surgery. Only English language studies that assessed the gender of surgical trainees with regards to operative cases for total and/or autonomously performed case numbers were included.

Results: Fifteen papers assessing the influence of gender on operative opportunities for trainee surgeons were identified. A discrepancy between the operative experiences of men and women trainee surgeons was found. Of eight studies assessing gender differences in total case numbers, four reported women undertaking fewer total cases than men; a similar trend was demonstrated in two studies that failed to reach statistical significance. Eight of eleven studies examining surgical autonomy reported more surgical autonomy afforded to men trainee surgeons than women.

Conclusions: A gendered bias in the operative opportunities afforded to trainee surgeons is suggested in the literature, reflecting implicit bias that underlies surgical culture worldwide. Although surgical specialties continue to have vast gender inequity, we fail to leverage talent and the benefits of diverse skills and experience, to the detriment of ourselves and our patients. Quantifying this issue will inform change.

Introduction: It is unclear if intracranial pressure monitoring (ICPM) after open cranial procedures (craniotomy or craniectomy) (OC) for traumatic brain injury is associated with mortality. We hypothesized that ICPM placed early after OC was associated with lower mortality compared to no ICPM or delayed ICPM placement.

Methods: Using 2020-2021 data from the American College of Surgeons Trauma Quality Improvement Program, patients ≥16 y from level 1 and 2 trauma centers who underwent OC were divided into two groups: ICPM placed within 72 h of OC (early) and no ICPM or ICPM placed after 72 h (none/delayed). Outcome was in-hospital mortality. Logistic regression was used to elucidate predictors of mortality.

Results: A total of 19,830 patients (early ICPM, 29%) were included. Early patients were more likely to be from level 1 centers (63% versus 60%, P = 0.004), younger (median age 47 versus 60, P < 0.0001), to have a lower Glasgow Coma Score (median, 6 versus 14, P < 0.0001), higher injury severity score (median, 26 versus 26, P < 0.0001), an unreactive pupil (33% versus 18%, P < 0.0001), midline shift >5 mm (69% versus 60%, P < 0.0001), received ≥2 units of blood/first 4 h (14% versus 6%, P < 0.0001) and higher mortality (31% versus 19%, P < 0.0001) compared to none/delayed patients. Controlled for significant variables, early ICPM was associated with increased mortality (odds ratio 1.35, 95% confidence interval 1.24-1.47). Analysis of subjects with isolated brain injury found a similar association (odds ratio 1.32, 95% C1 1.15-1.52).

Conclusions: ICPM placed within 72 h of OC was associated with increased mortality. Indications for ICPM after OC should be investigated further in multicenter prospective studies.

Introduction: Hospital-based violence intervention programs primarily target adults, raising questions about the effectiveness in preventing pediatric firearm deaths. We hypothesized that pediatric and adult firearm injury deaths are different enough to require unique intervention strategies.

Methods: Retrospective chart review was conducted of medical examiner and trauma center records of firearm-related deaths in the largest metropolitan county in Texas. Data from pediatric patients (0-17 ys) were compared to adults using chi-squared, Fischer's exact test, and Wilcoxon's rank-sum tests. In addition, data from younger children (0-15 ys) were further stratified and compared to adults (16 and above) using similar analyses.

Results: During 2018-2020, 117 pediatric and 1803 adult firearm deaths were identified. Homicide was most common in both groups (ped 58% versus adult 41%); however, differences were noted in unintentional shootings (ped 16% versus adult 1%, P < 0.01) and suicides (ped 21% versus adult 34%, P < 0.0 L). Alcohol abuse was more common in adults (ped 10% versus adult 46%, P < 0.01). Children <16 ys had a higher incidence in females (<16y 24% versus 16y+ 12%, P < 0.01), less alcohol abuse (<16y 6% versus 16y+ 62%, P < 0.01), less illegal drug use (<16y 19% versus 16y+ 46%, P < 0.01), and were more commonly killed at home (<16y 60% versus 16+y 43%, P < 0.01). Prevalent victim residence zip codes differed between children and adults.

Conclusions: Adult and pediatric firearm deaths differ in shooting intent and many key risk factors. These data can strategically inform focus areas for pediatric hospital-based violence intervention programs as well as resource allocation based on regional-level data.

Introduction: There is currently no consensus on the optimal surgical approach for the treatment of venous thoracic outlet syndrome (vTOS). Surgical exposures for vTOS decompression include infraclavicular (IC), supraclavicular (SC), paraclavicular (PC), and transaxillary (AX) approaches. The purpose of this study is to provide a comprehensive review of the outcomes and major complications of these four surgical techniques.

Methods: This meta-analysis was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We performed a systematic search in the Cochrane Library trials register, Scopus, PubMed, EMBASE, Google Scholar, and the US National Library of Medicine clinical trial databases for studies that evaluated the above four surgical exposures for vTOS and included them. Three independent reviewers assessed studies for inclusion, extracted data, and assessed quality and risk of bias. Primary outcomes of interest were clinical improvement and postoperative primary patency rate. Secondary outcomes included rates of nerve injury, hematoma, hemothorax, pneumothorax, and other complications. Pooled proportions with 95% confidence intervals (CIs) of various outcomes were calculated using a random-effects model. Subgroup analyses according to surgical approach were conducted.

Results: A total of twenty-six studies were included in the final analysis. The cumulative number of studies by surgical approach was 8 IC, 5 SC, 6 PC, and 11 AX. Pooled results from these studies demonstrated a 0.94 clinical improvement following surgical intervention (95% CI, 0.87-1), with a rate of 1 (95% CI, 0.99-1) for IC, 0.84 (95% CI, 0.38-1) for SC, 0.97 (95% CI, 0.76-1) for PC, and 0.88 (95% CI, 0.78-0.96) for AX approach. Overall, postoperative patency rate was 0.92 (95% CI, 0.84-0.97), with rate of 0.95 (95% CI, 0.89-1) for IC, 0.95 (95% CI, 0.78-1) for SC, 1 (95% CI, 0.98-1) for PC, and 0.69 (95% CI, 0.54-0.82) for AX approach. Subgroup analysis demonstrated a significantly higher rate of clinical improvement (0.12) in the IC group compared to the AX group. Rates of postoperative primary patency were higher in the IC (0.26), SC (0.26), and PC (0.31) groups than the AX group.

Conclusions: Our study highlights the importance of considering different surgical approaches for the decompression of vTOS. While the IC, SC, and PC methods demonstrate comparable postoperative primary patency and clinical improvement, the AX approach shows lower outcomes in these aspects. Surgeons should carefully weigh the benefits and limitations of each approach when determining the most suitable surgical technique for vTOS patients.

Introduction: We developed standardized electronic medical record templates (EMR-temp) for use in ambulatory prenatal surgical consultations for surgical fetal anomalies (SFAs). Our aim was to evaluate EMR-temp impact in provider documentation in prenatal care of SFA.

Methods: Prenatal consultations for SFAs at a single institution were retrospectively reviewed (2019-2022). Disease-specific EMR-templates were developed. Note content and time to encounter closure (TEC) were collected. Descriptive statistics, chi-square, Fisher's Exact Test, and Wilcoxon rank sum tests were used.

Results: Seven hundred twenty-four prenatal consultations were analyzed, with 131 consultations (18%) using EMR-temp for 55 (42%) congenital diaphragmatic hernia, 50 (38%) congenital lung malformations, 9 (7%) neural tube defects, 8 (6%) gastroschisis, and 9 (7%) heterotaxy. Overall median TEC was 23.9 hs [interquartile range (IQR) 1.3-128.6]. EMR-temp use decreases TEC from 28.4 hs [IQR 1.6-159.4] to 2.07 hs [IQR 0.85-76.2] (P < 0.001). The impact of EMR-temp varies depending on pathology. In congenital diaphragmatic hernia, EMR-temp decreased TEC 61%, from 52.0 [IQR 2.6-171.1] to 20.3 hs [IQR 1.5-55.5] (P = 0.01). In neural tube defect, EMR-temp decreased TEC 98% from 48.6 [IQR 2.6-157.1] to 1.02 hs [IQR 0.5-1.5] (P < 0.001). There were no differences in TEC with EMR-temp use in congenital lung malformation, gastroschisis and heterotaxy (P > 0.05). Across all diseases, EMR-temp had more comprehensive documentation of the following content: pathophysiology (92%), pregnancy planning (92%), delivery planning (84%), postnatal planning (95%), and long-term follow-up (90%) compared to nontemplates (P < 0.01).

Conclusions: EMR templates in SFA consultations improves encounter closure with comprehensive documentation of disease-specific pathophysiology and plans. However, impact varies across pathology, suggesting other factors are also important.