National Trends in the Creation of Diverting Ileostomy at the Time of Ileal Pouch-Anal Anastomosis in Adults With Ulcerative Colitis.

INTRODUCTION: The impact of diverting ileostomy in adults with ulcerative colitis (UC) undergoing ileal pouch-anal anastomosis (IPAA) is unclear. This study uses a novel approach with population-level data to identify patients with diverting ileostomy at the time of IPAA and determine the impact of diverting ileostomy on postoperative outcomes. METHODS: Using the International Business Machines (IBM) MarketScan® database, adults (18-64 years old) with a diagnosis of UC who underwent IPAA between 2000 and 2019 were examined. Patients were assigned to the diverting ileostomy (DI) cohort or no-DI cohort based on the presence of an ostomy closure code in the 1-year following their IPAA. Rates of ileostomy formation and readmissions were quantified and outcomes between cohorts compared. RESULTS: There were 540 patients in the no-DI and 2494 in the DI cohort. There were regional differences in the rate of ostomy creation, but the overall rate of ostomy creation remained stable across years. Patients with no-DI vs DI had a longer index length of stay (LOS) (7 vs 6 days, P = .001). Adverse postoperative outcomes did not differ between cohorts. Diversion did not independently affect the likelihood of a 30-day readmission, and since 2000, readmission rates have declined for all IPAA patients. DISCUSSION: This is the first study to capture population-level data on the effect of diversion at the time of IPAA for adult UC patients. This study demonstrates that the rate of fecal diversion at the time of IPAA has remained stable over time, but readmission rates have declined.

The treatment effect of operative intervention for flame versus scald burns in resource-limited settings.

INTRODUCTION: In resource-limited environments, it is critical to triage burn patients most likely to benefit from operative intervention. This study sought to identify patients with a more significant treatment effect after operative intervention following burn injury at a tertiary burn center in Lilongwe, Malawi. METHODS: This is a retrospective analysis of burn patients presenting to Kamuzu Central Hospital from 2011 to November 2022. We compared patients based on whether they had scald or flame burns. Using logistic regression, we estimated the adjusted treatment effect of operative intervention on in-hospital mortality. Operative intervention was defined as burn excision and debridement with or without skin grafting. RESULTS: We included 3266 patients. 2099 (64.7 %) patients had a scald burn, and 1144 (35.3 %) had a flame burn. 630 patients (19.3 %) underwent surgery. Crude mortality among all patients was 18.1 %, and for patients who underwent surgery, it was 9.7 %. When adjusted for total body surface area burned (TBSA) and age, the average treatment effect of surgery on mortality was - 0.07 (95 % CI - 0.11, - 0.033) for patients with scald burns and - 0.17 (95 % CI - 0.22, - 0.11) for patients with flame burns (Fig. 1). For patients with flame burns, the adjusted odds ratio of death associated with surgery was 0.26 (95 % CI 0.17, 0.39). CONCLUSIONS: Operative intervention confers a survival advantage for patients with flame burns, and the average treatment effect was more significant compared to patients with scald burns. In general, in resource-limited environments flame burns should be prioritized for surgery over scald burns to improve patient outcomes.

Neighborhood child opportunity is associated with hospital length of stay following pediatric burn injury.

INTRODUCTION: Pediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI) is a well-validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children. METHODS: We performed a single-institution retrospective review of pediatric (<16 years) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay. RESULTS: 2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 %) and low (n = 566, 29.2 %) COI neighborhoods. The proportion of non-Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 %) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 %) (p < 0.01). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 ± 4.1 vs. 3.2 ± 4.9 vs. 3.3 ± 4.8 vs. 2.8 ± 3.5 vs. 3.2 ± 8.1) (p = 0.02). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45-0.56). CONCLUSION: Children from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns. TYPE OF STUDY: Retrospective study LEVEL OF EVIDENCE: Level III.

An evaluation of the "Obesity Paradox" in isolated blunt abdominal trauma in the United States.

BACKGROUND: The obesity paradox theorizes a survival benefit in trauma patients secondary to the cushioning effect of adiposity. We aim to evaluate the impact of body mass index (BMI) on abdominal injury severity, morbidity, and mortality in adults with isolated, blunt abdominal trauma in the United States. METHODS: We reviewed the National Trauma Data Bank (2013-2021) for adults sustaining isolated, blunt abdominal trauma stratified by BMI. We performed a doubly robust, augmented inverse-propensity weighted multivariable logistic regression to estimate the average treatment effect (ATE) of BMI on mortality and the presence of abdominal organ injury. RESULTS: 36,350 patients met the inclusion criteria. In our study, 41.4 % of patients were normal-weight (BMI 18.5-24.9), 20.6 % were obese (BMI 30-39.9), and 4.7 % were severely obese (BMI≥40). In these cohorts, the abdominal abbreviated injury scale (AIS) was 2 (2 -3). Obese and severely obese patients had significantly reduced presence of pancreas, spleen, liver, kidney, and small bowel injuries. The predicted probability of abdominal AIS severity decreased significantly with increasing BMI. Crude mortality was significantly higher in obese (1.3 %) and severely obese patients (1.3 %) compared to normal-weight patients (0.7 %). Obese and severely obese patients demonstrated non-statistically significant changes in the mortality of +26.4 % (ATE 0.264, 95 %CI -0.108-0.637, p = 0.164) and +55.5 % (ATE 0.555, 95 %CI -0.284-1.394, p = 0.195) respectively, compared to normal weight patients. CONCLUSION: BMI may protect against abdominal injury in adults with isolated, blunt abdominal trauma. Mortality did not decrease in association with increasing BMI, as this may be offset by the increase in co-morbidities in this population.

Linking the preference in a bilateral asymmetric task with handedness, footedness, and eyedness: The case of ice-hockey.

Most people know whether they are left-handed or right-handed, and usually base this assessment on preferences during one-handed tasks. There are several manual tasks that require the contribution of both hands, in which, in most cases, each hand plays a different role. In this specific case, holding an ice-hockey stick is particularly interesting because the hand placement may have an incidence on the playing style. In this study (n = 854), the main objective was to determine to what extent the way of holding an ice-hockey stick is associated with other lateralized preferences. Amongst the 131 participants reporting a preference for the left hand in unilateral tasks, 70.2% reported a preference for shooting right (placing the right hand in the middle of the stick); and amongst the 583 participants reporting a preference for writing with the right hand, 66.2% reported a preference for shooting left. 140 (16.4%) participants were classified as ambidextrous and 61.4% of them reported a preference for shooting right. This preference on the ice-hockey stick is closely correlated (uncrossed preference) to the way one holds a rake, shovel, or broom, or a golf club, but inversely related to the way one holds an ax and a baseball bat. The link between the way of holding the ice-hockey stick and eyedness or footedness is weak. These results are contrasted with the results reported by Loffing et al. (2014) and reveal the need to clarify the exact nature and requirements of the targeted tasks when studying bilateral asymmetric preferences.

Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery.

BACKGROUND: There are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact. METHODS: Key concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries. RESULTS: The guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas. CONCLUSION: The article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

Transfusion and Mortality in Acute Care Surgical Patients in Malawi: A Propensity-Matched Analysis.

INTRODUCTION: Information on transfusion-associated outcomes is limited in sub-Saharan Africa. We sought to characterize predictors of mortality in transfused patients with acute care surgical conditions in Malawi. METHODS: We performed a retrospective propensity-matched analysis of patients with acute care surgical conditions at Kamuzu Central Hospital in Malawi from 2013 to 2021. We compared outcomes between patients who did and did not receive transfusions. RESULTS: A total of 7395 patients were included. Transfused patients (n = 1086) were older (median 43 y with interquartile range 30-59, versus 39 y [interquartile range 27-53] in the nontransfused group, P < 0.01), had a higher proportion of females (41% versus 27%, P < 0.01), presented earlier to the hospital (median 2.9 versus 3.7 d, P = 0.02), and with lower hemoglobin levels (27% versus 1% < 7 g/dL, P < 0.01). They had a lower rate of surgical intervention (48% versus 59%, P < 0.01) but a higher rate of complications (62% versus 33%, P < 0.01). Crude in-hospital mortality was 25.5% for the transfused group and 12.8% for the nontransfused group (P < 0.01). After propensity matching, transfused patients had three times the odds of mortality compared to nontransfused patients (odds ratio 3.3, 95% confidence interval 2.3, 4.8). CONCLUSIONS: In this propensity-matched study, transfused surgical patients were more likely to experience in-hospital mortality. These results suggest that the transfusion requirement reflects critical illness and warrants further investigation in this low-resource setting.

Evaluating Global Surgery Partnerships From Low and Middle Income Country Perspectives.

INTRODUCTION: Little is known about perceptions of low-income and middle-income country (LMIC) partners regarding global surgery collaborations with high-income countries (HICs). METHODS: A survey was distributed to surgeons from LMICs to assess the nature and perception of collaborations, funding, benefits, communication, and the effects of COVID-19 on partnerships. RESULTS: We received 19 responses from LMIC representatives in 12 countries on three continents. The majority (83%) had participated in collaborations within the past 5 y with 39% of collaborations were facilitated virtually. Clinical and educational partnerships (39% each) were ranked most important by respondents. Sustainability of the partnership was most successfully achieved in domains of education/training (78%) and research (61%). The majority (77%) of respondents reported expressing their needs before HIC team arrival. However, 54% of respondents were the ones to initiate the conversation and only 47% said HIC partners understood the overall environment well at arrival to LMIC. Almost all participants (95%) felt a formal process of collaboration and a structured partnership would benefit all parties in assessing needs. During the COVID-19 pandemic, 87% of participants reported continued collaborations; however, 44% of partners felt that relationships were weaker, 31% felt relationships were stronger, and 25% felt they were unchanged. CONCLUSIONS: Our study provides a snapshot of LMIC surgeons' perspectives on collaboration in global surgery. Independent of location, LMIC partners cite inadequate structure for long-term collaborations. We propose a formal pathway and initiation process to assess resources and needs at the outset of a partnership.

Predictors of Functional Decline Among Critically Ill Surgical Patients: A National Analysis.

INTRODUCTION: Functional decline is associated with critical illness, though this relationship in surgical patients is unclear. This study aims to characterize functional decline after intensive care unit (ICU) admission among surgical patients. METHODS: We performed a retrospective analysis of surgical patients admitted to the ICU in the Cerner Acute Physiology and Chronic Health Evaluation database, which includes 236 hospitals, from 2007 to 2017. Patients with and without functional decline were compared. Predictors of decline were modeled. RESULTS: A total of 52,838 patients were included; 19,310 (36.5%) experienced a functional decline. Median ages of the decline and nondecline groups were 69 (interquartile range 59-78) and 63 (interquartile range 52-72) years, respectively (P < 0.01). The nondecline group had a larger proportion of males (59.1% versus 55.3% in the decline group, P < 0.01). After controlling for sociodemographic covariates, comorbidities, and disease severity upon ICU admission, patients undergoing pulmonary (odds ratio [OR] 6.54, 95% confidence interval [CI] 2.67-16.02), musculoskeletal (OR 4.13, CI 3.51-4.87), neurological (OR 2.67, CI 2.39-2.98), gastrointestinal (OR 1.61, CI 1.38-1.88), and skin and soft tissue (OR 1.35, CI 1.08-1.68) compared to cardiovascular surgeries had increased odds of decline. CONCLUSIONS: More than one in three critically ill surgical patients experienced a functional decline. Pulmonary, musculoskeletal, and neurological procedures conferred the greatest risk. Additional resources should be targeted toward the rehabilitation of these patients.

Outcomes in Obese Adult Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review.

Obesity is associated with an overall increased risk of morbidity and mortality. However, in patients with critical illness, sepsis, and acute respiratory distress syndrome, obesity may be protective, termed "the obesity paradox." This is a systematic literature review of articles published from 2000 to 2022 evaluating complications and mortality in adults with respiratory failure on veno-venous extracorporeal membrane oxygenation (VV ECMO) based on body mass index (BMI). Eighteen studies with 517 patients were included. Common complications included acute renal failure (175/377, 46.4%), venous thrombosis (175/293, 59.7%), and bleeding (28/293, 9.6%). Of the six cohort studies, two showed improved mortality among obese patients, two showed a trend toward improved mortality, and two showed no difference. Comparing all patients in the studies with BMI of less than 30 to those with BMI of greater than or equal to 30, we noted decreased mortality with obesity (92, 37.1% of BMI <30 vs. 30, 11% of BMI ≥30, p ≤ 0.0001). Obesity may be protective against mortality in adult patients undergoing VV ECMO. Morbid and super morbid obesity should not be considered a contraindication to cannulation, with patients with BMI ≥ 80 surviving to discharge. Complications may be high, however, with higher rates of continuous renal replacement therapy and thrombosis among obese patients.

Cues to care: Chronic disease diagnosis in young adult trauma patients.

BACKGROUND: Prevention of chronic disease necessitates early diagnosis and intervention. In young adults, a trauma admission may be an early contact with the health care system, representing an opportunity for screening and intervention. This study estimates the prevalence of previously diagnosed disease and undiagnosed disease (UD)-diabetes mellitus, hypertension, obesity, and alcohol and substance use-in a young adult trauma population. We determine factors associated with UD and examine outcomes in patients with UD. METHODS: This is a multicenter, retrospective cohort study of adult trauma patients 18 to 40 years old admitted to participating Level I trauma centers between January 2018 and December 2020. Three Level 1 trauma centers in a single state participated in the study. Trauma registry data and chart review were examined for evidence of previously diagnosed disease or UD. Patient demographics and outcomes were compared between cohorts. Multivariable regression modeling was performed to assess risk factors associated with any UD. RESULTS: The analysis included 6,307 admitted patients. Of these, 4,843 (76.8%) had evidence of at least 1 UD, most commonly hypertension and obesity. In multivariable models, factors most associated with risk of UD were age (adjusted odds ratio [aOR], 0.98; 95% confidence interval [CI], 0.98-0.99), male sex (aOR, 1.43; 95% CI, 1.25-1.63), and uninsured status (aOR, 1.57; 95% CI, 1.38-1.80). Only 24.5% of patients had evidence of a primary care provider (PCP), which was not associated with decreased odds of UD. Clinical outcomes were significantly associated with the presence of chronic disease. Of those with UD and no PCP, only 11.2% were given a referral at discharge. CONCLUSION: In the young adult trauma population, the UD burden is high, especially among patients with traditional sociodemographic risk factors and even in patients with a PCP. Because of short hospital stays in this population, the full impact of UD may not be visible during a trauma admission. Early chronic disease diagnosis in this population will require rigorous, standard screening measures initiated within trauma centers. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Predictors of mortality following electrical and lightning injuries in Malawi: A decade of experience.

INTRODUCTION: Electrical injuries can be devastating, and data is lacking in low-resource settings. We aimed to identify predictors of mortality following electrical and lightning injuries (ELI) in Malawi. METHODS: We performed a retrospective observational study of patients presenting with ELI and burn injuries at a tertiary hospital in Malawi from 2011 to 2020. Outcomes were compared and predictors of mortality were modeled. RESULTS: A total of 382 ELI and 6371 burn patients were included. The mean ages for ELI and burn groups were 24 ± 14 and 11 ± 14 years, respectively (p < 0.01). Most patients were injured at home (91% in the burn group versus 51% in the ELI group, p < 0.01). The crude mortality rate in the ELI group was 28%, compared to 12% in the burn group (p < 0.01). On multivariate logistic regression, predictors of mortality included ELI (odds ratio [OR] 13.3, 95% confidence interval [CI] 7.2-24.5) and total body surface area burned (OR 1.1, 95% CI 1.1-1.1). Predicted mortality for ELI has increased over time (p = 0.05). CONCLUSIONS: ELI confers more than 13 times higher odds of mortality than burn injuries in Malawi, with mortality risk increasing over time. More efforts are needed to prevent electrical hazards and implement timely interventions for patients with ELI.

The Timing of Operative Intervention for Pediatric Burn Patients in Malawi.

BACKGROUND: Defining the optimal timing of operative intervention for pediatric burn patients in a resource-limited environment is challenging. We sought to characterize the association between mortality and the timing of operative intervention at a burn center in Lilongwe, Malawi. METHODS: This is a retrospective analysis of burn patients (<18 years old) presenting to Kamuzu Central Hospital from 2011 to 2022. We compared patients who underwent excision and/or burn grafting based on the timing of the operation. We used logistic regression modeling to estimate the adjusted odds ratio of death based on the timing of surgery. RESULTS: We included 2502 patients with a median age of 3 years (IQR 1-5) and a male preponderance (56.8%). 411 patients (16.4%) had surgery with a median time to surgery of 18 days (IQR 8-34). The crude mortality rate among all patients was 17.0% and 9.1% among the operative cohort. The odds ratio of mortality for patients undergoing surgery within 3 days from presentation was 5.00 (95% CI 2.19, 11.44) after adjusting for age, sex, % total burn surface area (TBSA), and flame burn. The risk was highest for the youngest patients. CONCLUSIONS: Children who underwent burn excision and/or grafting in the first 3 days of hospitalization had a much higher risk of death than patients undergoing surgical intervention later. Delaying operative intervention till >72 h for pediatric patients, especially those under 5 years old, may confer a survival advantage. More investment is needed in early resuscitation and monitoring for this patient population.

Who benefits from resuscitative thoracotomies following penetrating trauma: The patient or the learner?

BACKGROUND: Resuscitative thoracotomy (RT) is a salvage procedure following traumatic cardiac arrest. We aim to evaluate RT trends and outcomes in adults with cardiac arrest following penetrating trauma to determine the effect on mortality in this population. Further, we aim to estimate the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality. METHODS: We reviewed the National Trauma Data Bank (2017-2021) for adults (≥16 years old) with penetrating trauma and prehospital cardiac arrest, stratified by the performance of a RT. We performed multivariable logistic regressions to estimate the effect of RT on mortality and the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality. RESULTS: 13,115 patients met our inclusion criteria. RT occurred in 12.7% (n = 1,664) of patients. Rates of RT trended up over the study period. Crude mortality was similar in RT and Non-RT patients (95.6% vs. 94.5%, p = 0.07). There was no statistically significant difference in the adjusted odds of mortality based on RT status (OR 0.82, 95%CI 0.56-1.21). University-teaching hospitals had an adjusted odds ratio of 1.68 (95% CI 1.31-2.17) for performing a RT than non-teaching hospitals. There was no difference in the adjusted odds of mortality in patients that underwent RT based on hospital teaching status. CONCLUSION: Despite up-trending rates, a resuscitative thoracotomy may not improve mortality in adults with penetrating, traumatic cardiac arrest. University teaching hospitals are nearly twice as likely to perform a RT than non-teaching hospitals, with no subsequent improvement in mortality.