American Surgeon最新文献

The creation of a blowhole colostomy can be an effective option for patients with large bowel obstruction and severe abdominal disease. However, they are often difficult to manage secondary to poor appliance fitting, peristomal dermatitis, and pain. In 2021, a case series describing a novel technique using a Dacron Vascular Prosthesis (VUP medical, Brno, Czech Republic) sutured to the mucocutaneous junction to help with stoma management was described. In the following case study, we share our experience with placement of a Hemashield Gold Dacron Graft (Maquet Cardiovascular, LLC, Wayne, NJ, USA) as a last resort in the management of a blowhole colostomy in a patient with large bowel obstruction secondary to metastatic carcinoid tumor. Compared to the previously described technique, we used a shorter graft, non-absorbable suture (Nylon, Ethicon, Cincinnati, OH, USA) and took larger bites of the mucocutaneous junction to achieve improved quality of life.

Background: The use of illicit substances during pregnancy has increased 4-fold in the past two decades, negatively impacting both mother and fetus. The rate and clinical outcomes of substance use in pregnant trauma patients (PTPs) are not well studied. We sought to evaluate clinical outcomes of PTPs with positive urine toxicology, hypothesizing a higher rate of in-hospital maternal complications for PTPs with a positive urine toxicology ((+)Utox) compared to those testing negative ((-)Utox). Methods: PTPs (≥18 years old) were included in this multicenter retrospective study between 2016 and 2021. We included patients with known urine toxicology results and compared (+)Utox vs (-)Utox PTPs. Results: From 852 PTPs, 84 (9.8%) had a (+)Utox with the most common illicit substance being THC (57%) followed by methamphetamine (44%). (+)Utox PTPs had higher rates of blunt head injury (9.5% vs 4.2%, P = .028), extremity injury (14.3% vs 6.5%, P = .009), domestic violence (21.4% vs 5.9%, P < .001), suicide attempt (3.6% vs 0.3%, P < .001), and uterine contractions (46% vs 23.5%, P < .001). Abnormal fetal heart tracing, premature rupture of membranes and placental injury were similar between groups (all P > .05). The rate of maternal complications was similar in both groups (all P > .05). Conclusion: In this study, the rate of (+)Utox in PTPs was 9.8%. The (+)Utox group had similar rates of maternal complications but more commonly experienced uterine contractions which may be related to the physiology of drugs such as methamphetamines. PTPs with (+)Utox also more commonly were victims of domestic violence and suicide attempt, which merits further prevention research efforts.

Background: Gun violence disproportionately affects metropolitan areas of the United States (US). There is limited information regarding the influence of social determinants of health, such as food insecurity (FI) on firearm homicide mortality (FHM) in major metropolitan cities in the US. We sought to examine the relationship between FI and FHM.

Materials and methods: This was a cross-sectional analysis examining the largest 51 US major metropolitan statistical areas (MSAs) using data from 2018. Demographic data, markers of social inequities, and firearm homicide data were obtained from the US Census Bureau, US Department of Education, and the Frey and Brookings Institute. Food insecurity prevalence was obtained from Feeding America. Spearman ρ and linear regression were performed.

Results: Using Spearman rho analysis, higher FI (r = 0.55, P < 0.001) was associated with FHM. Other variables associated with FHM included percent Black/African American (AA) (r = 0.77, P < 0.001), poverty rate (r = 0.53, P < 0.001), and percent of children living in single parent households (r = 0.58, P < 0.001). In linear regression analyses, FI was associated with increased FHM, with 1.3 additional FHM events for each unit increase in FI (β = 1.33, 95% CI 0.27-2.39, P = 0.02). The percent of a population that is Black/AA was also associated with FHM, with more than 4 additional cases for each 1% increase in the population (β = 4.32, 95% CI 3.26-5.38, P < 0.001).

Conclusion: Food insecurity may influence FHM in major US metropolitan cities. Community- and hospital-based programs that target FI may help combat the gun violence epidemic and decrease gun violence.

Post-traumatic stress disorder (PTSD) was first introduced as a diagnosis by the American Psychiatric Association in 1980. This diagnosis, included in the 3rd edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III), was to be considered after someone was exposed to a traumatic event "outside the range of usual human experience and would be markedly distressing to almost anyone." Since then, trauma survivors have been identified as being at risk for the development of post-traumatic stress symptom (PTSS) and post-traumatic stress disorder (PTSD). Despite the recognition of this fact, the screening, recognition, and diagnosis of PTSD in these at-risk populations are inconsistent. In the following review, which is designed for the clinician who is unfamiliar with PTSD and its recognition, diagnosis, and treatment, we introduce the problem in the trauma patient and define its scope. In addition, we discuss the diagnosis of PTSD in trauma patients, special considerations relating to these patient populations, treatment options, and explore future directions for how best to define, study, recognize, and treat this challenging and potentially devastating condition.

Introduction: Communication with families is essential to improve satisfaction, especially in the critical care setting. We sought to identify patients who were not recovering as expected and to improve communication with their families.Methods: We implemented a novel algorithm, incorporating clinical and social criteria, to determine which patients could benefit from additional communication. Patients who qualified were randomized to the intervention of a structured interdisciplinary family meeting or to standard communication in the Intensive Care Unit at the discretion of the attending. Surveys were administered to both groups to determine the primary outcome of satisfaction with communication. Wilcoxon rank-sum, chi-square, or Fisher's exact test as appropriate was used to compare baseline characteristics and survey items between groups.Results: There was no difference between the intervention (n = 25) and non-intervention groups (n = 33) in demographic or clinical characteristics (P-value >.05). Surveys were able to be completed for 76% of the intervention group and 51% in the non-intervention group. There was no difference in the responses to the survey between the groups (P-value >.05), signifying that families were satisfied with communication regardless of whether they had a structured interdisciplinary family meeting.Conclusion: Our results are contrary to the traditionally held belief that structured family meetings improve communication. A possible explanation is that implementing an algorithm to identify patients in need of additional communication predisposes providers to be more cognizant of family needs in the Surgical Intensive Care Unit. Future research should focus on qualitative research to elucidate what aspects of communication are most useful to families.

Purpose: Current society guidelines recommend purse-string closure technique for stoma reversal, which has been shown to reduce but not eliminate the risk of deep surgical site infection (SSI) at the original stoma site, a complication associated with increased morbidity and cost. We studied an adjunctive technique to further reduce the risk of SSI. Methods: A retrospective chart review was conducted on adult patients who underwent stoma reversal between May 2016 - July 2022. Stoma reversal was performed with purse-string closure, and placement of a strip of povidone-iodine soaked non-adherent pad in the remaining two cm opening at the prior stoma site. This pad was taken out on post-operative day one and changed to wet-to-dry saline moistened gauze. Results: 82 patients were identified. The cohort had a median BMI 26.5 [IQR 23.0-31.0] and median age 57.5 [IQR 45.8-67.0]. Mean time from original surgery to reversal was nine months. 59.8% identified as female, 24.4% were currently smoking, 18.3% were had diabetes. The cohort experienced a 11.0% readmission rate and 18.3% rate of stoma site hernia with a mean follow up of 17 17 months. No patient developed an SSI. Conclusion: In this cohort study with known risk factors for SSI, no patients undergoing stoma reversal experienced a post-operative SSI. The adjunctive technique of a povidone-iodine soaked non-adherent pad in addition to purse-string closure should be further examined in conjunction with surgical bundles to reduce the risk of SSI and overall morbidity of stoma reversal surgery.

Introduction: Obtaining a categorical general surgery residency position is recognized as a highly challenging process, and many aspiring surgeons find themselves matching into a preliminary position. The American Board of Surgery In-Training Examination (ABSITE) is relevant as a discriminator, as it is the only national evaluation metric that compares residents between programs. This study examines the correlation between ABSITE performance and the likelihood of obtaining a categorical position for non-designated preliminary surgery residents.

Methods: Retrospective analysis of preliminary residents who completed the ABSITE between 2011 and 2021 at a single academic training program.

Results: 108 preliminary residents were included. Among preliminary residents who were successful in securing a categorical position, the average ABSITE percentile was 59 (SD = 26.7). In contrast, those who were not able to secure a categorical position, the average ABSITE percentile was 23.6 (SD = 25.3). There was a strong significant correlation between ABSITE percentile and securing a categorical position (P < 0.001). There was a significant association between citizenship and gaining a categorical position, with US citizens being significantly more likely to successfully gain a categorical position (P = 0.01; OR 3.32 (95% CI 1.28-8.56)). There was not a significant correlation between citizenship and ABSITE score.

Conclusion: This study presents compelling evidence that ABSITE percentile score is positively associated with the probability of securing a categorical position for preliminary general surgery residents. It is therefore imperative that both preliminary residents and their programs place a high value on ABSITE performance to enhance successful career progression.

Strongyloidiasis is a rare systemic parasitic infection caused by the nematode, Strongyloides stercoralis, that is often insidious and may remain dormant for many years before progressing to fulminant hyperinfection in an immunocompromised host. In this report, we present a case of disseminated strongyloidiasis in a patient who underwent a deceased donor kidney transplantation 2 months prior to presentation. Our patient developed multisystem organ failure as well as secondary hemophagocytic lymphohistiocytosis (HLH) and ultimately died despite extensive resuscitative efforts and antiparasitic treatments. This report highlights the importance of routine screening for parasitic diseases prior to organ transplantation, especially with donors from endemic regions of the world.

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport.Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression.Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients.Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation.