Severe BCG immune reconstitution inflammatory syndrome lymphadenitis successfully managed with pre-antiretroviral counseling and a non-surgical approach: a case report.

BACKGROUND: Bacillus Calmette-Guérin (BCG) reactions are the most common cause of immune reconstitution inflammatory syndrome (IRIS) in HIV-positive infants who initiate antiretroviral therapy (ART). There is limited evidence regarding the incidence of BCG-IRIS; however, reports from outpatient cohorts have estimated that 6-9% of infants who initiated ART developed some form of BCG-IRIS within the first 6 months. Various treatment approaches for infants with BCG-IRIS have been reported, but there is currently no widely accepted standard-of-care. CASE PRESENTATION: A 5-month-old male HIV-exposed infant BCG vaccinated at birth was admitted for refractory oral candidiasis, moderate anemia, and moderate acute malnutrition. He had a HIV DNA-PCR collected at one month of age, but the family never received the results. He was diagnosed with HIV during hospitalization with a point-of-care nucleic acid test and had severe immune suppression with a CD4 of 955 cells/µL (15%) with clinical stage III disease. During pre-ART counseling, the mother was educated on the signs and symptoms of BCG-IRIS and the importance of seeking follow-up care and remaining adherent to ART if symptoms arose. Three weeks after ART initiation, he was readmitted with intermittent subjective fevers, right axillary lymphadenopathy, and an ulcerated papule over the right deltoid region. He was subsequently discharged home with a diagnosis of local BCG-IRIS lymphadenitis. At six weeks post-ART initiation, he returned with suppurative lymphadenitis of the right axillary region that had completely eviscerated through the skin without signs of disseminated BCG disease. He was then started on an outpatient regimen of topical isoniazid, silver nitrate, and oral prednisolone. Throughout this time, the mother maintained good ART adherence despite this complication. After 2.5 months of ART and one month of specific treatment for the lymphadenitis, he had marked mass reduction, improved adenopathy, increased CD4 count, correction of anemia, and resolution of his acute malnutrition. He completely recovered and was symptom free two months after initial treatment without surgical intervention. CONCLUSIONS: This case details the successful management of severe suppurative BCG-IRIS with a non-surgical approach and underlines the importance of pre-ART counseling on BCG-IRIS for caregivers, particularly for infants who initiate ART with advanced HIV.

The Presence of a Cost-Volume Relationship in Robotic-assisted Thoracoscopic Lung Resections.

OBJECTIVE: To characterize the relationship between institutional robotic-assisted pulmonary lobectomy volume and hospitalization costs. BACKGROUND: The high cost of robotic-assisted thoracoscopic surgery (RATS) is among several drivers of hesitation among nonadopters. Studies examining the impact of institutional experience on costs of RATS lobectomy are lacking. METHODS: Adults undergoing RATS lobectomy for primary lung cancers were identified from the 2016 to 2018 Nationwide Readmissions Database. A multivariable regression to model hospitalization costs was developed with the inclusion of hospital RATS lobectomy volume as restricted cubic splines. The volume corresponding to the inflection point of the spline was used to categorize hospitals as high- (HVH) or low-volume (LVH). We subsequently examined the association of HVH status with adverse events, length of stay, costs, and 30-day, nonelective readmissions. RESULTS: An estimated 14,756 patients underwent RATS lobectomy during the study period, with median cost of $23,000. Upon adjustment for patient and operative characteristics, hospital RATS volume was inversely associated with costs. Although only 17.2% of centers were defined as HVH, 51.7% of patients were managed at these centers. Patients at HVH and LVH had similar age, sex, and distribution of comorbidities. Notably, patients at HVH had decreased risk-adjusted odds of adverse events (adjusted odds ratio: 0.62, P <0.001), as well as significantly reduced length of stay (-0.8 d, P <0.001) and costs (-$3900, P <0.001). CONCLUSIONS: Increasing hospital RATS lobectomy volume was associated with reduced hospitalization costs. Our findings suggest the presence of streamlined care pathways at high-volume centers, which influence costs of care.

Postoperative length of stay following kidney transplantation in patients without delayed graft function-An analysis of center-level variation and patient outcomes.

BACKGROUND: Early discharge after surgical procedures has been proposed as a novel strategy to reduce healthcare expenditures. However, national analyses of the association between discharge timing and post-transplant outcomes following kidney transplantation are lacking. METHODS: This was a retrospective cohort study of all adult kidney transplant recipients without delayed graft function from 2014 to 2019 in the Organ Procurement and Transplantation Network and Nationwide Readmissions Databases. Recipients were divided into Early (LOS ≤ 4 days), Routine (LOS 5-7), and Delayed (LOS > 7) cohorts. RESULTS: Of 61 798 kidney transplant recipients, 26 821 (43%) were discharged Early and 23 279 (38%) Routine. Compared to Routine, patients discharged Early were younger (52 [41-61] vs. 54 [43-62] years, p < .001), less commonly Black (33% vs. 34%, p < .001), and more frequently had private insurance (41% vs. 35%, p < .001). After adjustment, Early discharge was not associated with inferior 1-year patient survival (Hazard Ratio [HR] .74, 95% Confidence Interval [CI] 0.66-0.84) or increased likelihood of nonelective readmission at 90-days (HR .93, CI .89-.97), relative to Routine discharge. Discharging all Routine patients as Early would result in an estimated cost saving of ∼$40 million per year. Multi-level modeling of post-transplantation LOS revealed that 28.8% of the variation in LOS was attributable to interhospital differences rather than patient factors. CONCLUSIONS: Early discharge after kidney transplantation appears to be cost-efficient and not associated with inferior post-transplant survival or increased readmission at 90 days. Future work should elucidate the benefits of early discharge and develop standardized enhanced recovery protocols to be implemented across transplant centers.

Brain Health Living Labs.

We call on geriatric brain health care providers, executives and entrepreneurs to embrace our Brain Health Living Lab model-a user-centered, iterative ecosystem, integrating concurrent clinical care, research and innovation processes.

Patterns of variation and covariation in the shapes of mandibular bones of juvenile salmonids in the genus Oncorhynchus.

What is the nature of evolutionary divergence of the jaw skeleton within the genus Oncorhynchus? How can two associated bones evolve new shapes and still maintain functional integration? Here, we introduce and test a "concordance" hypothesis, in which an extraordinary matching of the evolutionary shape changes of the dentary and angular articular serves to preserve their fitting together. To test this hypothesis, we examined morphologies of the dentary and angular articular at parr (juvenile) stage, and at three levels of biological organization­between salmon and trout, between sister species within both salmon and trout, and among three types differing in life histories within one species, Oncorhynchus mykiss. The comparisons show bone shape divergences among the groups at each level; morphological divergence between salmon and trout is marked even at this relatively early life history stage. We observed substantial matching between the two mandibular bones in both pattern and amount of shape variation, and in shape covariation across species. These findings strongly support the concordance hypothesis, and reflect functional and/or developmental constraint on morphological evolution. We present evidence for developmental modularity within both bones. The locations of module boundaries were predicted from the patterns of evolutionary divergences, and for the dentary, at least, would appear to facilitate its functional association with the angular articular. The modularity results suggest that development has biased the course of evolution.

Common Pediatric Urologic Conditions: Contemporary Management of Cryptorchidism, the Retractile Testis, and Phimosis.

Undescended testis is the most common genital disorder identified at birth. Boys who do not have spontaneous descent of the testis at 6 months of age, adjusted for gestational age, should be referred to pediatric urology for timely orchiopexy. Retractile testes are at risk for secondary ascent of the testes and should be monitored by physical examination annually. If there is concern for ascent of the testis, pediatric urology referral is recommended. Most cases of phimosis can be managed medically with topical corticosteroids and manual retraction of the foreskin.

In search of a neuropsychological profile for migraine: A scoping review.

OBJECTIVE: Migraine is commonly overlooked by the general population and by professionals in research and clinical practice. Moreover, it is difficult to grasp the neuropsychological profile of migraineurs due to the cyclic nature of the disorder. With this in mind, a scoping review of the literature was conducted with the goal of characterizing cognitive domains associated with deficits in migraine. METHODS: PubMed, PsychInfo, Scopus, EMBASE and OpenGrey databases were searched for studies published from 1st January 2006 to 30th November 2022. Following the review process, 52 eligible studies were included in the review. RESULTS: Studies included in this review show mixed and sometimes contradictory findings. Overall, both visual and auditory perception appear to be impaired. Deficits on attention, many memory processes, visuospatial function and spatial navigation and on a wide range of executive functions (set-shifting and cognitive flexibility, decision-making and reasoning, working memory and prospective memory) complete a complex cognitive profile in migraine. Lack of consistency across studies in sample selection and sizes, lack of detailed links between cognitive deficits and specific migraine phases, or length and chronicity, inconsistencies on the role of aura in cognitive function; and heterogeneity and sometimes questionable reliability and validity of some of the cognitive measures used may affect the clarity and consistency of results observed. CONCLUSION: Further research properly addressing the role of gender and age, migraine stage, length and chronicity of the condition, the effect of aura and comorbidities is needed, alongside increasing consistency across diverse neuropsychological assessment protocols. SIGNIFICANCE: This review provides a comprehensive, up-to-date picture of the current status of knowledge in relation to the characterization of the complex cognitive profile of migraine. It offers detailed information of the existing research gaps and challenges to improve the cognitive characterization of migraine across its different stages and leads clinicians to carefully consider the selection of relevant cognitive tasks, in order to grasp more accurately the patient's cognitive profile; an assessment that should be an integral part of any protocol developed for the clinical assessment and subsequent treatment planning for migraine.

A Community Development Approach in Physical Therapist Education.

Physical therapists should be able to screen patients for social determinants that impact health and refer to community resources as appropriate. To make appropriate referrals, physical therapists must equip themselves with skills to connect patients and clients to community resources outside the walls of their respective institutions, starting with developing these practices in physical therapist education programs.Experienced community builders recommend a community development approach where residents initiate and agree upon decisions, and outside stakeholders work as partners to elevate the community. The community should be supported to determine the desired outcomes in ways that enhance equity, inclusion, and social justice. Communities play a substantial role in health outcomes. Studies indicate that 85% of one's health is connected to community and economic resources, while only 15% is affected by medical interventions. Connected communities are potent tools to enhance health. Connected communities are places where residents nurture neighborhood relationships that enable them to work together to create a good life supporting their collective well-being.The community-builder approach recenters people and their communities as fundamental health leaders; institutions can use their resources to elevate communities by relocating authority back to communities. Communities have assets and resources largely unrecognized, disconnected, and not mobilized by residents. Institutions are positioned to support citizens and their associations in discovering, connecting, and mobilizing these assets. This asset-based community development (ABCD) approach focuses on 5 principles: place-based, citizen-led, relationship-oriented, asset-based, and inclusion-focused.This perspective paper will describe ways institutions can elevate communities; the benefits of community development practices in physical therapist education programs; and explore examples of community partnerships and best practices to develop equitable alliances with residents in the community. IMPACT: A large part of one's health is directly related to where one lives. Physical therapists and physical therapist assistants can play a vital role in improving the health of society by engaging in their local communities through community development. Community development is a practice where community members and outside stakeholders, such as physical therapists, come together to meet the needs of a community.

Culturally Responsive Pedagogy in Physical Therapy Education.

The push for holistic admissions practices in physical therapy education has evoked concerns that learners who are culturally and linguistically diverse might be less qualified than the predominant demographic traditionally admitted into programs. The implications are that culturally and linguistically diverse learners struggle academically and experience challenges passing the National Physical Therapy Examination. However, as the academic preparedness of learners is discussed, rarely does the conversation include the capabilities of faculty to teach these learners. As cohorts continue to include learners from a greater variety of backgrounds and identities, the largely homogenous professorate, with more than 80% identifying as White, might need training in culturally responsive pedagogy to best serve learners from all backgrounds and identities. Educators often use a "one-size-fits-all" approach in which learners are expected to use the same resources and pace for assignments, readings, and assessments, regardless of their learning strengths or academic preparation. That approach fails to empower educators to design curricula and instruction to position all learners to excel in the classroom. This Perspective explores strategies to support all learners through three dimensions of culturally responsive pedagogy: institutional, personal, and instructional. To truly transform society, we must first transform physical therapy education. Culturally responsive pedagogy advances and supports all student achievement by recognizing, fostering, and using their strengths in the learning environment.

Equitable Grading Practices in Physical Therapist Education: A Case Report.

OBJECTIVE: To optimize learning in physical therapist education, learners need opportunities to grow from their unique starting points. Traditional grading practices like A to F grades, zero grades, and grading on timeliness and professionalism hinder content mastery and accurate competency assessment. Grading should focus on mastery of skill and content, using summative assessments for final grades, a no-zero policy, and actionable feedback. Equitable grading supports learners from all backgrounds and identities and promotes academic success. This case study provides guidance and recommendations for implementing equitable grading practices in academic physical therapist programs. METHODS: Over a 2-year period, a doctor of physical therapy program began implementing 5 strategies to create more equitable grading practices: (1) eliminating zero grades, (2) allowing late assignment submissions without penalty, (3) using low-stakes formative assessments throughout the semester, (4) weighing end-of-course assessments more heavily than initial ones, and (5) offering a no-stakes anatomy prep course before matriculation. RESULTS: Outcomes from implementing equitable grading practices varied. Some learners felt increased stress from fewer points opportunities, while others appreciated the reduced anxiety from low-stakes assessments. Some saw multiple attempts for peers as unfair. Faculty faced higher workloads due to detailed feedback and remediation but believed it benefited learners. Median final grades improved in some courses, remained stable in others, and slightly decreased in one. Overall, the changes had minimal impact on most learners' grades but significantly improved outcomes and retention for struggling learners. CONCLUSION: This case report documents the implementation of equitable grading practices in a Doctor of Physical Therapy program, offering valuable insights and recommendations for other institutions aiming to adopt similar practices. IMPACT: Inequity in assessment widens the gap between learners entering professional programs. Equitable assessment practices level the playing field, enabling learners from diverse backgrounds and identities to succeed. Increased diversity benefits everyone, especially patients, by reducing health disparities for historically marginalized groups.

How Integrating the 5 Pillars of Community Practice Can Transform Physical Therapist Education and Reduce Health Disparities.

Patient history assists clinicians in determining the most appropriate tests to identify the symptoms' source and select appropriate interventions. Therefore, a subjective history is an essential component of patient management. When physical therapist practitioners transition into academia, they must understand how the history of the education system may affect learners. Health disparities are related to the lack of workforce diversity and skills in cultural responsiveness, and the education system is critical in addressing the impact of future providers on health disparities. Developing a Doctor of Physical Therapy (DPT) program to address health disparities requires an analysis of the historical context of the United States (US) educational and health care systems, along with traditional components of physical therapist education. This country's education system was built upon a 2-tiered system, where minoritized individuals struggled to overcome barriers imposed by legislation and societal beliefs. Jim Crow laws continued this unequal access to education, and the recent Supreme Court ruling to deny race-based affirmative action continues these inequities. This historical context informed the construction of the College of Saint Mary (CSM) DPT Program. The program's mission led to using less traditional educational approaches; thus, the pillars of practice took form. The 5 pillars evolved to include social determinants, inclusive faculty and student recruitment and retention practices, equitable grading, culturally responsive pedagogy, and community development. The purpose of this paper is to present a historical overview of the United States education system and its influence on physical therapist education. Furthermore, it will illustrate how this historical context inspired the 5 Pillars of Community Practice from CSM and discuss the challenges and interventions related to these pillars. There are tremendous disparities in educational outcomes and patient services in the US. Disparities are most significant in those with historically marginalized identities. If those disparities are to improve, a change is required in the people providing care to patients. The best way to accomplish this is by transforming how future providers are educated.

Disparities in outpatient rural cholecystectomy outcomes.

BACKGROUND: Previous studies showed comparable outcomes for common in-patient general surgery operations, but it is unknown if this extends to outpatient operations. Our aim was to compare outpatient cholecystectomy outcomes between rural and urban hospitals. METHODS: A retrospective cohort analysis was done using the Nationwide Ambulatory Surgery Sample for patients 20-years-and-older undergoing cholecystectomy between 2016 and 2018 â€‹at rural and urban hospitals. Survey-weighted multivariable regression analysis was performed with primary outcomes including use-of-laparoscopy, complications, and patient discharge disposition. RESULTS: The most common indication for operation was cholecystitis in both hospital settings. On multivariable analysis, rural hospitals were associated with higher transfers to short-term hospitals (adjusted odds ratio [aOR] 2.40, 95%CI 1.61-3.58, p â€‹< â€‹0.01) and complications (aOR 1.39, 95%CI 1.11-1.75, p â€‹< â€‹0.01). No difference was detected with laparoscopy (aOR 1.93, 95%CI 0.73-5.13, p â€‹= â€‹0.19), routine discharge (aOR 1.50, 95%C I0.91-2.45, p â€‹= â€‹0.11), or mortality (aOR 3.23, 95%CI 0.10-100.0, p â€‹= â€‹0.51). CONCLUSIONS: Patients cared for at rural hospitals were more likely to be transferred to short-term hospitals and have higher complications. No differences were detected in laparoscopy, routine discharge or mortality.

Identifying the origin of socioeconomic disparities in outcomes of major elective operations.

Background: While the impact of socioeconomic status (SES) on surgical outcomes has been examined in limited series, it remains a significant determinant of healthcare outcomes at the national level. Therefore, the current study aims to determine SES disparities at three time-points: hospital accessibility, in-hospital outcomes, and post-discharge consequences. Methods: The Nationwide Readmissions Database 2010-2018 was used to isolate major elective operations. SES was assigned using previously coded median income quartiles as defined by patient zip-code, with low SES defined as the lowest quartile and high SES as the highest. Results: Of an estimated 4,816,837 patients undergoing major elective operations, 1,037,689 (21.3 %) were categorized as low SES and 1,288,618 (26.5 %) as high. On univariate analysis and compared to those of low SES, high SES patients were more frequently treated at high-volume centers (70.9 vs 55.6 %, p < 0.001), had lower rates of in-hospital complications (24.0 vs 29.0 %, p < 0.001) and mortality (0.4 vs 0.9 %, p < 0.001) as well as less frequent urgent readmissions at 30- (5.7 vs 7.1 %, p < 0.001) and 90-day timepoints (9.4 vs 10.7 %, p < 0.001). On multivariable analysis, high SES patients had higher odds of treatment at high-volume centers (Odds: 1.87, 95 % CI: 1.71-2.06), and lower odds of perioperative complications (Odds: 0.98, 95 % CI: 0.96-0.99), mortality (Odds: 0.70, 95 % CI: 0.65-0.75), and urgent readmissions at 90-days (Odds: 0.95, 95 % CI: 0.92-0.98). Conclusion: This study fills a much-needed gap in the current literature by establishing that all of the aforementioned timepoints include significant disadvantages for those of low socioeconomic status. Therefore, a multidisciplinary approach may be required for intervention to improve equity for surgical patients.

Cost Variation and Value of Care in Pulmonary Lobectomy Across the United States.

BACKGROUND: Optimization of value, or quality relative to costs, has garnered significant attention in the United States. We aimed to characterize center-level variation in costs and quality after pulmonary lobectomy using a national cohort. METHODS: Adults undergoing elective pulmonary lobectomy were identified in the 2016 to 2018 Nationwide Readmissions Database. Quality was defined by the absence of major adverse outcomes including respiratory failure, acute kidney injury, reoperation, and death. Risk-adjusted adverse outcome rates and costs were studied for institutions performing greater than or equal to 10 operations annually. Using observed-to-expected (O/E) ratios, high-value hospitals were defined as those with an O/E ratio less than 1 for costs and O/E ratio less than 1 for quality, while low-value hospitals were defined by the converse. RESULTS: Among 95 446 patients managed at 565 hospitals annually, the median center-level cost for lobectomy was $22 000 (interquartile range, $18 000-$27 000), while the median adverse outcome rate was 14.3% (interquartile range, 8.3%-23.1%). Centers with an O/E ratio less than 1 for adverse events exhibited a $2200/case reduction in risk-adjusted costs. Using O/E ratios, 35.2% of centers were classified as high value while 18.6% were low value. Compared with low-value centers, high-value centers treated older patients (67.1 years of age vs 65.5 years of age; P < .001) with greater comorbidities (Elixhauser Comorbidity Index 3.7 vs 2.9; P < .001) but had greater annual lobectomy volume (40 cases vs 30 cases; P = .001) and were more commonly teaching hospitals. CONCLUSIONS: Significant variation in costs and quality persists for lobectomy at the national level. Although high-value programs operated on patients at greater surgical risk, they had reduced complications and costs. Our findings suggest the need for dissemination of quality improvement and cost reduction practices.

Care Fragmentation After Hospitalization for Acute Myocardial Infarction.

Care fragmentation (CF), or readmission at a nonindex hospital, has been linked to inferior clinical and financial outcomes for patients. However, its impact on patients with acute myocardial infarction (AMI) is unclear. This study investigated the prevalence and impact of CF on the outcomes of patients with AMI. All US adult (≥18 years) hospitalizations for AMI from January 2010 to November 2019 were identified using the Nationwide Readmissions Database. Patients were stratified by readmission at an index or nonindex center. Multivariable models were developed to evaluate factors associated with CF, and independent associations with mortality, complications, and resource utilization. A total of 413,819 patients with AMI requiring nonelective readmission within 30 days of discharge were included for analysis. Of these, 25.4% (n = 104,966) experienced CF. The incidence of CF increased from 2010 to 2019 (nptrend <0.001). After adjustment, patients insured by Medicaid faced higher odds of nonindex readmission. CF was associated with in-hospital mortality (adjusted odds ratio [AOR] 1.09, 95% confidence interval [CI] 1.01 to 1.18), and cardiac (AOR 1.12, 95% CI 1.03 to 1.22), respiratory (AOR 1.14, 95% CI 1.12 to 1.26), and infectious complications (AOR 1.14, 95% CI 1.07 to 1.22). Further, CF was linked to increased odds of nonhome discharge (AOR 1.18, 95% CI 1.11 to 1.24) and an additional ∼$5,000 in per-patient hospitalization costs (95% CI 4,260 to 5,100). Approximately 25% of AMI patients experienced CF, which was independently associated with excess mortality, complications, and expenditures. Given the growing national burden of cardiovascular disease, new efforts are needed to mitigate the significant clinical and financial implications of nonindex readmissions and improve value-based healthcare.

Racial disparities in outcomes for extracorporeal membrane oxygenation in the United States.

BACKGROUND: Racial disparities in extracorporeal membrane oxygenation (ECMO) outcomes in patients with a broad set of indications are not well documented. METHODS: Adults requiring ECMO were identified in the 2016-2019 National Inpatient Sample. Patient and hospital characteristics, including mortality, clinical outcomes, and resource utilization were analyzed using multivariable regressions. RESULTS: Of 43,190 adult ECMO patients, 67.8% were classified as White, 18.1% Black, and 10.4% Hispanic. Although mortality for Whites declined from 47.5 to 41.0% (P = 0.002), it remained steady for others. Compared to White, Asian/Pacific Islander (PI) race was linked to increased odds of mortalty (AOR = 1.4, 95% CI = 1.1-2.0). Black race was associated with increased odds of acute kidney injury (AOR = 1.4, 95%-CI: 1.2-1.7), while Hispanic race was linked to neurologic complications (AOR 21.6; 95% CI 1.2-2.3). Black and Hispanic race were also associated with increased incremental costs. CONCLUSIONS: Race-based disparities in ECMO outcomes persist in the United States. Further work should aim to understand and mitigate the underlying reasons for such findings.

Bariatric surgery improves outcomes of hospitalizations for acute heart failure: a contemporary, nationwide analysis.

BACKGROUND: The link between obesity and poor outcomes in heart failure (HF) has been well-established. OBJECTIVES: This retrospective study sought to examine national rates and outcomes of acute HF hospitalizations in obese individuals with a prior history of bariatric surgery. SETTING: Academic, university-affiliated; the United States. METHODS: Adult admissions (≥18 years) including a diagnosis of severe obesity were identified in the 2016-2019 Nationwide Readmissions Database. Patients who previously underwent bariatric operations were categorized into the Bariatric cohort. Multivariable linear and logistic models were used to assess the association of prior bariatric surgery with outcomes of interest. RESULTS: Of an estimated 10,343,828 admissions for a diagnosis of severe obesity, 925,716 (8.9%) comprised the bariatric cohort. After risk adjustment, bariatric surgery was associated with significantly decreased odds of acute HF hospitalization (adjusted odds ratio [AOR]: .40, 95% confidence interval [CI]: .38-.41). Among acute HF hospitalizations, prior bariatric surgery was linked to lower odds of mortality (AOR: .68, 95% CI: .52-.89), prolonged mechanical ventilation (AOR .44, 95% CI: .32-.61), acute renal failure (AOR: .76, 95% CI: .70-.82), and prolonged hospitalization (AOR: .77, 95% CI: .68-.87). Bariatric surgery was linked to a decrement of 1 day (95% CI: .7-1.1) and $1200 in hospitalization costs (95% CI: 400-1900), but no significant difference in odds of 30-day readmission. CONCLUSIONS: Bariatric surgery is associated with reduced admissions for acute HF. Among acute HF hospitalizations, bariatric surgery is linked to significantly improved clinical and financial outcomes. Given its potential benefits in obesity and related diseases, bariatric surgery holds promise for promoting value-based healthcare for HF.

Clinical and financial outcomes of transplant recipients following emergency general surgery operations.

Introduction: Due to immunosuppression and underlying comorbidities, transplant recipients represent a vulnerable population following emergency general surgery (EGS) operations. The present study sought to evaluate clinical and financial outcomes of transplant patients undergoing EGS. Methods: The 2010-2020 Nationwide Readmissions Database was queried for adults (≥18 years) with non-elective EGS. Operations included bowel resection, perforated ulcer repair, cholecystectomy, appendectomy and lysis of adhesions. Patients were classified by transplant history (Non-transplant, Kidney/Pancreas, Liver, Heart/Lung). The primary outcome was in-hospital mortality while perioperative complications, resource utilization and readmissions were secondarily considered. Multivariable regression models evaluated the association of transplant status on outcomes. Entropy balancing was employed to obtain a weighted comparison to adjust for intergroup differences. Results: Of 7,914,815 patients undergoing EGS, 25,278 (0.32 %) had prior transplantation. The incidence of transplant patients increased temporally (2010: 0.23 %, 2020: 0.36 %, p < 0.001) with Kidney/Pancreas comprising the largest proportion (63.5 %). Non-transplant more frequently underwent appendectomy and cholecystectomy while transplant patients more commonly received bowel resections. Following entropy balancing, Liver was associated with decreased odds of mortality (AOR: 0.67, 95 % CI: 0.54-0.83, Reference: Non-transplant). Incremental hospitalization duration was longer in Liver and Heart/Lung compared to Non-transplant. Odds of acute kidney injury, readmissions and costs were higher in all transplant types. Conclusion: The incidence of transplant recipients undergoing EGS operations has increased. Liver was observed to have lower mortality compared to Non-transplant. Transplant recipient status, regardless of organ, was associated with greater resource utilization and non-elective readmissions. Multidisciplinary care coordination is warranted to mitigate outcomes in this high-risk population.

Impact of delayed intervention following admission for small bowel obstruction: A contemporary analysis.

Background: The optimal timing of surgical intervention for small bowel obstruction (SBO) remains debated. Methods: All adults admitted for SBO were identified in the 2018-2019 National Inpatient Sample. Patients undergoing small bowel resection or lysis of adhesion after three days were considered part of the Delayed cohort. All others were classified as Early. Multivariable regressions were used to assess independent predictors of delayed surgical intervention as well as associations between delayed management and in-hospital mortality, major adverse events (MAE), perioperative complications, postoperative length of stay (LOS), hospitalization costs and non-home discharge. Results: Among 28,440 patients who met study criteria, 52.0 % underwent delayed intervention. Black race (AOR 1.19, 95 % CI 1.03-1.36, ref.: White) and Medicare coverage (AOR 1.16, 95 % CI 1.01-1.33, ref.: private payer) were associated with increased odds of delayed surgical management. While delayed intervention was not significantly associated with death (AOR 1.27, 95 % CI 0.97-1.68), it was linked to greater odds of MAE (AOR 1.30, 95 % CI 1.16-1.45) and several perioperative complications. The Delayed cohort also faced an incremental increase in postoperative LOS (+1.29 days, 95 % CI 0.89-1.70) and hospitalization costs (+$11,000, 95 % CI 10,000-12,000). Moreover, delayed intervention was linked to increased odds of non-home discharge (AOR 1.64, 95 % CI 1.47-1.84). Conclusions: Delay in surgical management following SBO is linked to inferior clinical outcomes and increased resource use. Our findings highlight the need to ensure proper timing of surgery for SBO as well as efforts to standardize these practices across all demographics of patients.

National trends and resource associated with recurrent penetrating injury.

BACKGROUND: While recurrent penetrating trauma has been associated with long-term mortality and disability, national data on factors associated with reinjury remain limited. We examined temporal trends, patient characteristics, and resource utilization associated with repeat firearm-related or stab injuries across the US. METHODS: This was a retrospective study using 2010-2019 Nationwide Readmissions Database (NRD). NRD was queried to identify all hospitalizations for penetrating trauma. Recurrent penetrating injury (RPI) was defined as those returned for a subsequent penetrating injury within 60 days. We quantified injury severity using the International Classification of Diseases Trauma Mortality Prediction model. Trends in RPI, length of stay (LOS), hospitalization costs, and rate of non-home discharge were then analyzed. Multivariable regression models were developed to assess the association of RPI with outcomes of interest. RESULTS: Of an estimated 968,717 patients (28.4% Gunshot, 71.6% Stab), 2.1% experienced RPI within 60 days of the initial injury. From 2010 to 2019, recurrent gunshot wounds increased in annual incidence while that of stab cohort remained stable. Patients experiencing recurrent gunshot wounds were more often male (88.9 vs 87.0%, P<0.001), younger (30 [23-40] vs 32 [24-44] years, P<0.001), and less commonly insured by Medicare (6.5 vs 11.2%, P<0.001) compared to others. Those with recurrent stab wounds were younger (36 [27-49] vs 44 [30-57] years, P<0.001), less commonly insured by Medicare (21.3 vs 29.3%, P<0.001), and had lower Elixhauser Index Comorbidities score (2 [1-3] vs 3 [1-4], P<0.001) compared to others. After risk adjustment, RPI of both gunshot and stab was associated with significantly higher hospitalization costs, a shorter time before readmission, and increased odds of non-home discharge. CONCLUSION: The trend in RPI has been on the rise for the past decade. National efforts to improve post-discharge prevention and social support services for patients with penetrating trauma are warranted and may reduce the burden of RPI.