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Record-breaking summer forest fires have become a regular occurrence in California. Observations indicate a fivefold increase in summer burned area (BA) in forests in northern and central California during 1996 to 2021 relative to 1971 to 1995. While the higher temperature and increased dryness have been suggested to be the leading causes of increased BA, the extent to which BA changes are due to natural variability or anthropogenic climate change remains unresolved. Here, we develop a climate-driven model of summer BA evolution in California and combine it with natural-only and historical climate simulations to assess the importance of anthropogenic climate change on increased BA. Our results indicate that nearly all the observed increase in BA is due to anthropogenic climate change as historical model simulations accounting for anthropogenic forcing yield 172% (range 84 to 310%) more area burned than simulations with natural forcing only. We detect the signal of combined historical forcing on the observed BA emerging in 2001 with no detectable influence of the natural forcing alone. In addition, even when considering fuel limitations from fire-fuel feedbacks, a 3 to 52% increase in BA relative to the last decades is expected in the next decades (2031 to 2050), highlighting the need for proactive adaptations.
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PURPOSE: Understanding the complication profile of craniosynostosis surgery is important, yet little is known about complication co-occurrence in syndromic children after multi-suture craniosynostosis surgery. We examined concurrent perioperative complications and predictive factors in this population. METHODS: In this retrospective cohort study, children with syndromic diagnoses and multi-suture involvement who underwent craniosynostosis surgery in 2012-2020 were identified from the National Surgical Quality Improvement Program-Pediatric database. The primary outcome was concurrent complications; factors associated with concurrent complications were identified. Correlations between complications and patient outcomes were assessed. RESULTS: Among 5,848 children identified, 161 children (2.75%) had concurrent complications: 129 (2.21%) experienced two complications and 32 (0.55%) experienced ≥ 3. The most frequent complication was bleeding/transfusion (69.53%). The most common concurrent complications were transfusion/superficial infection (27.95%) and transfusion/deep incisional infection (13.04%) or transfusion/sepsis (13.04%). Two cardiac factors (major cardiac risk factors (odds ratio (OR) 3.50 [1.92-6.38]) and previous cardiac surgery (OR 4.87 [2.36-10.04])), two pulmonary factors (preoperative ventilator dependence (OR 3.27 [1.16-9.21]) and structural pulmonary/airway abnormalities (OR 2.89 [2.05-4.08])), and preoperative nutritional support (OR 4.05 [2.34-7.01]) were independently associated with concurrent complications. Children who received blood transfusion had higher odds of deep surgical site infection (OR 4.62 [1.08-19.73]; p = 0.04). CONCLUSIONS: Our results indicate that several cardiac and pulmonary risk factors, along with preoperative nutritional support, were independently associated with concurrent complications but procedural factors were not. This information can help inform presurgical counseling and preoperative risk stratification in this population.
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Craniossinostoses , Procedimentos Neurocirúrgicos , Humanos , Criança , Estudos Retrospectivos , Procedimentos Neurocirúrgicos/métodos , Infecção da Ferida Cirúrgica/etiologia , Craniossinostoses/complicações , Craniossinostoses/cirurgia , Fatores de Risco , Suturas/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgiaRESUMO
Importance: Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial. Objective: To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia. Design, Setting, and Participants: A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023. Interventions: In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age. Main Outcomes and Measures: The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period. Results: Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup). Conclusions and Relevance: Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit. Trial Registration: ClinicalTrials.gov Identifier: NCT01678638.
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Hérnia Inguinal , Herniorrafia , Recém-Nascido Prematuro , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Asiático/estatística & dados numéricos , Teorema de Bayes , Idade Gestacional , Hérnia Inguinal/epidemiologia , Hérnia Inguinal/etnologia , Hérnia Inguinal/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Herniorrafia/estatística & dados numéricos , Alta do Paciente , Fatores Etários , Hispânico ou Latino/estatística & dados numéricos , Brancos/estatística & dados numéricos , Estados Unidos/epidemiologia , Negro ou Afro-Americano/estatística & dados numéricosRESUMO
INTRODUCTION: Upper gastrointestinal (UGI) series is often part of the workup prior to the placement of gastrostomy tubes in children. Prior studies have suggested UGI to be limited in utility and an extra financial burden. The goal of this study was to investigate the utility and cost of UGI studies. METHODS: A retrospective, case control study of patients aged < 18 y receiving gastrostomy tubes at a free-standing children's hospital between 2012 and 2017. Total costs were obtained from the Pediatric Health Information System. RESULTS: Six hundred eighty five patients underwent gastrostomy placement during the study period. UGI was obtained in 90.8% of patients; 23.6% of studies were abnormal. The most common abnormal findings were reflux (13.8%) and abnormal anatomy (5.8%). The median time to obtain a UGI was 0.82 d (interquartile range 0.22-1.05). Obtaining a UGI was associated with delayed care in 104 patients (15.2%). If a delay was encountered, median time was 2.47 d (interquartile range 1.86-2.99). Ladd's procedures were performed in 12 patients (1.7%) found to have malrotation on UGI. None of the 63 patients who did not undergo UGI required a Ladd's procedure. Patients that had a UGI did not experience an increase in overall length of stay (14.3 versus 15.6 d, excluding intensive care unit patients), operative time (34 versus 39 min), or a change in rate of operative complications (11.5% versus 14.3%). In addition, UGI did not have a significant impact on total adjusted costs ($49,844 versus $83,438 without UGI, P = 0.12) but did slightly increase total adjusted costs per day ($2212 versus $1999 without UGI, P = 0.01). CONCLUSIONS: UGI prior to gastrostomy placement in children rarely identified abnormal findings that changed the operative plan, was associated with delayed care in 15% of patients, and was associated with slightly increased costs per day. Further analyses to identify subsets of children that may benefit from routine UGI are warranted.
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Refluxo Gastroesofágico , Gastrostomia , Humanos , Criança , Gastrostomia/efeitos adversos , Gastrostomia/métodos , Estudos Retrospectivos , Estudos de Casos e Controles , Refluxo Gastroesofágico/cirurgia , Trânsito GastrointestinalRESUMO
INTRODUCTION: With the expansion of pediatric surgery fellowships from 2008 to 2018, there is concern for the dilution of training experience, especially for rare index cases. The Accreditation Council for Graduate Medical Education (ACGME) established required minimum case numbers by case type, but this is a program requirement rather than an individual trainee requirement. The American Board of Surgery (ABS) is considering instituting minimum case requirements across 5 broad categories for individuals to be board-eligible in pediatric surgery. METHODS: The ACGME National Data Report summary case logs were obtained for graduating fellows in pediatric surgery from 2008 to 2018. Median case volumes were compared to minimum ACGME case numbers and proposed ABS individual requirements. Using Poisson distributions, probabilities of individual fellows failing to meet minimum case numbers were calculated. RESULTS: The average annual probability that a median program would fail to meet minimum ACGME case numbers in at least 1 category was estimated at 16.6%. Using the proposed ABS system, the probability of failure was estimated at 44.1%. No temporal trend was found in the annual probability of failure in either the ACGME or the proposed ABS system. CONCLUSIONS: There is significant risk of a fellow failing to meet case minimums in the ACGME system and the proposed ABS system. This probability is increased for the half of programs below median. If the ABS institutes case minimums as a requirement for certification in pediatric surgery, the current training paradigm may be impacted at some programs.
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Bolsas de Estudo , Cirurgia Geral/educação , Pediatria/educação , Carga de Trabalho/estatística & dados numéricos , Acreditação , Educação de Pós-Graduação em Medicina , Humanos , Distribuição de Poisson , Conselhos de Especialidade Profissional , Estados UnidosRESUMO
Ovarian tissue cryopreservation is the only fertility preservation (FP) option available to prepubescent females receiving gonadotoxic therapy, but it has limited availability. A 6-year-old female was diagnosed with high-risk rhabdomyosarcoma, and the planned treatment carried an 80% risk of ovarian failure. Her parents desired FP, but the nearest center was 500 miles away. The patient underwent oophorectomy at the cancer center with air transport of the tissue to the oncofertility center, where it was successfully cryopreserved. Formation of networks between full-service and limited oncofertility centers in a hub-and-spoke model would increase access to FP services, particularly in children.
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Criopreservação , Preservação da Fertilidade , Neoplasias , Rabdomiossarcoma , Viagem Aérea , Criança , Feminino , Humanos , Neoplasias/terapia , Ovariectomia , Planejamento de Assistência ao Paciente , Rabdomiossarcoma/terapiaRESUMO
Children with trisomy 18 are surviving longer and undergoing more aggressive life-sustaining therapy. This report describes two patients with trisomy 18 and hepatoblastoma (HB) successfully resected in the setting of significant pulmonary hypertension. Forty-four previously published cases of the association between HB and trisomy 18 are reviewed. With careful multidisciplinary preoperative planning, successful resection of HB in children with trisomy 18 who have significant pulmonary hypertension is feasible. Because HB and trisomy 18 are increasing in prevalence, the need for timely liver tumor resection in the setting of pulmonary hypertension will be more common.
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Anestésicos/administração & dosagem , Hepatectomia/métodos , Hepatoblastoma/cirurgia , Hipertensão Pulmonar/cirurgia , Neoplasias Hepáticas/cirurgia , Síndrome da Trissomía do Cromossomo 18/cirurgia , Feminino , Hepatoblastoma/complicações , Hepatoblastoma/tratamento farmacológico , Hepatoblastoma/patologia , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/tratamento farmacológico , Hipertensão Pulmonar/patologia , Lactente , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/tratamento farmacológico , Neoplasias Hepáticas/patologia , Prognóstico , Síndrome da Trissomía do Cromossomo 18/complicações , Síndrome da Trissomía do Cromossomo 18/tratamento farmacológico , Síndrome da Trissomía do Cromossomo 18/patologiaRESUMO
This is Part II of a review covering the wide range of issues associated with all aspects of the use and responsible disposal of foam and plastic wastes containing toxic or potentially toxic flame retardants. We identify basic and applied research needs in the areas of responsible collection, pretreatment, processing, and management of these wastes. In Part II, we explore alternative technologies for the management of halogenated flame retardant (HFR) containing wastes, including chemical, mechanical, and thermal processes for recycling, treatment, and disposal.
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Flame retardants (FRs) are added to foams and plastics to comply with flammability standards and test requirements in products for household and industrial uses. When these regulations were implemented, potential health and environmental impacts of FR use were not fully recognized or understood. Extensive research in the past decades reveal that exposure to halogenated FRs, such as those used widely in furniture foam, is associated with and/or causally related to numerous health effects in animals and humans. While many of the toxic FRs have been eliminated and replaced by other FRs, existing products containing toxic or potentially toxic chemical FRs will remain in use for decades, and new products containing these and similar chemicals will permeate the environment. When such products reach the end of their useful life, proper disposal methods are needed to avoid health and ecological risks. To minimize continued human and environmental exposures to hazardous FR chemicals from discarded products, waste management technologies and processes must be improved. This review discusses a wide range of issues associated with all aspects of the use and responsible disposal of wastes containing FRs, and identifies basic and applied research needs in the areas of responsible collection, pretreatment, processing, and management of these wastes.
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OBJECTIVES: To define the incidence of 90-day readmission and characterize the factors associated with 90-day readmission after 10 major surgical procedures. BACKGROUND: Most data on readmission focus solely on same hospital readmission (index hospitals) within 30 days of discharge. These studies may underestimate readmission, as patients may be readmitted beyond 30 days of discharge or to other non-index hospitals. METHODS: Patients discharged after 10 major surgical procedures (coronary artery bypass grafting, abdominal aortic aneurysm repair, carotid endarterectomy, aortic valve replacement, esophagectomy, pancreatectomy, pulmonary resection, hepatectomy, colectomy, and cystectomy) between 2010 and 2012 were identified from the Truven Health MarketScan Commercial Claims and Encounters database. Multivariable logistic regression analysis was performed to identify determinants of early (≤30 days) and late (31-90 days) readmission. RESULTS: A total of 158,753 patients were identified; 60.3% were male, and 42.3% had a Charlson Comorbidity Index of 2 or more. A total of 26,817 (16.9%) patients were readmitted within 90 days [early: 16,419 (10.4%) vs late: 10,398 (6.5%)]. Among readmitted patients, 38.3% were readmitted to a different hospital than the index hospital. Both early and late readmissions were more common at the index versus non-index hospital (early: 83.9% vs 16.1%; late: 75.0% vs 25.0%; both P < 0.001). In-hospital mortality after early readmission and late readmission was found to be lower at index hospitals than that at non-index hospitals (early; 0.7% vs 2.5%, P = 0.04; late; 0.2% vs 2.0%, P = 0.02). CONCLUSIONS: More than one-third of readmission occurred after 30 days of index discharge. Approximately 20% of patients were readmitted to non-index hospitals. Assessment of 30 day same hospital readmissions underestimated the true incidence of readmission.
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Planos de Assistência de Saúde para Empregados/economia , Custos Hospitalares , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/métodos , Centros Médicos Acadêmicos , Idoso , Estudos de Coortes , Bases de Dados Factuais , Feminino , Planos de Assistência de Saúde para Empregados/estatística & dados numéricos , Custos de Cuidados de Saúde , Humanos , Tempo de Internação/economia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Alta do Paciente/economia , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/economia , Fatores de TempoRESUMO
Readmission is a large problem after both medical and surgical admissions. Recent policy changes that include substantial financial penalties have made readmission an important, if not the most important, pay-for-performance program for health care in the United States. The CMS Hospital Readmissions Reduction Program currently applies only to patients with certain medical diagnoses, but it is expanding into orthopedic surgery in 2014, and will likely involve more surgical procedures in the future. Accordingly, hospitals and researchers will increasingly be focused on understanding and preventing readmission. Definitions of readmission must be standardized between organizations to allow for comparison. The accepted definition for any organization tracking rehospitalization should be 30-day all-cause readmission. In addition, any hospital profiling applications or studies comparing readmission rates between hospitals should use hierarchical rather than standard logistic regression modeling. Rather than relying on findings from medical patients, further studies on the specific causes of readmission after surgery should be conducted. Predictive modeling has some utility in focusing readmission prevention efforts on high-risk patients, but understanding the underlying causes of readmission is key to designing effective prevention interventions. Current evidence suggests that postoperative complications play a key role in surgical readmission, but efforts on improving discharge planning and coordination of care developed in medical patients will also be critical in decreasing unnecessary readmissions in the future.
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Readmissão do Paciente/estatística & dados numéricos , Comorbidade , Política de Saúde/legislação & jurisprudência , Humanos , Tempo de Internação , Medicare , Readmissão do Paciente/economia , Complicações Pós-Operatórias , Fatores de Risco , Estados UnidosRESUMO
INTRODUCTION: Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured. MATERIALS AND METHODS: This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race. RESULTS: There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications. CONCLUSIONS: Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system.
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PURPOSE: There is limited information on the clustering or co-occurrence of complications after spinal fusion surgery for neuromuscular disease in children. We aimed to identify the frequency and predictive factors of co-occurring perioperative complications in these children. METHODS: In this retrospective database cohort study, we identified children (ages 10-18 years) with neuromuscular scoliosis who underwent elective spinal fusion in 2012-2020 from the National Surgical Quality Improvement Program-Pediatric database. The rates of co-occurring complications within 30 days were calculated, and associated factors were identified by logistic regression analysis. Correlation between a number of complications and outcomes was assessed. RESULTS: Approximately 11% (709/6677 children with neuromuscular scoliosis undergoing spinal fusion had co-occurring complications: 7% experienced two complications and 4% experienced ≥ 3. The most common complication was bleeding/transfusion (80%), which most frequently co-occurred with pneumonia (24%) and reintubation (18%). Surgical time ≥ 400 min (odds ratio (OR) 1.49 [95% confidence interval (CI) 1.25-1.75]), fusion ≥ 13 levels (1.42 [1.13-1.79]), and pelvic fixation (OR 1.21 [1.01, 1.44]) were identified as procedural factors that independently predicted concurrent complications. Clinical risk factors for co-occurring complications included an American Society of Anesthesiologist physical status classification ≥ 3 (1.73 [1.27-2.37]), structural pulmonary/airway abnormalities (1.24 [1.01-1.52]), impaired cognitive status (1.80 [1.41-2.30]), seizure disorder (1.36 [1.12-1.67]), hematologic disorder (1.40 [1.03-1.91], preoperative nutritional support (1.34 [1.08-1.72]), and congenital malformations (1.20 [1.01-1.44]). Preoperative tracheostomy was protective against concurrent complications (0.62 [0.43-0.89]). Significant correlations were found between number of complications and length of stay, non-home discharge, readmissions, and death. CONCLUSION: Longer surgical time (≥ 400 min), fusion ≥ 13 levels and pelvic fixation are surgical risk factors independently associated with co-occurring complications, which were associated with poorer patient outcomes. Recognizing identified nonmodifiable risk factors might also be important for preoperative planning and risk stratification of children with neuromuscular scoliosis requiring spinal fusion. LEVEL OF EVIDENCE: Level IV evidence.
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Complicações Pós-Operatórias , Escoliose , Fusão Vertebral , Humanos , Fusão Vertebral/efeitos adversos , Escoliose/cirurgia , Criança , Adolescente , Feminino , Masculino , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Doenças Neuromusculares/complicações , Doenças Neuromusculares/epidemiologia , Fatores de Risco , Fatores de Tempo , Duração da Cirurgia , Pneumonia/epidemiologia , Pneumonia/etiologiaRESUMO
BACKGROUND: Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment. METHODS: Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question. RESULTS: The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered. CONCLUSION: Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.
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OBJECTIVE: The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee conducted a systematic review to describe the epidemiology of venous thromboembolism (VTE) in pediatric surgical and trauma patients and develop recommendations for screening and prophylaxis. METHODS: The Medline (Ovid), Embase, Cochrane, and Web of Science databases were queried from January 2000 through December 2021. Search terms addressed the following topics: incidence, ultrasound screening, and mechanical and pharmacologic prophylaxis. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available literature. RESULTS: One hundred twenty-four studies were included. The incidence of VTE in pediatric surgical populations is 0.29% (Range = 0.1%-0.48%) and directly correlates with surgery type, transfusion, prolonged anesthesia, malignancy, congenital heart disease, inflammatory bowel disease, infection, and female sex. The incidence of VTE in pediatric trauma populations is 0.25% (Range = 0.1%-0.8%) and directly correlates with injury severity, major surgery, central line placement, body mass index, spinal cord injury, and length-of-stay. Routine ultrasound screening for VTE is not recommended. Consider sequential compression devices in at-risk nonmobile, pediatric surgical patients when an appropriate sized device is available. Consider mechanical prophylaxis alone or with pharmacologic prophylaxis in adolescents >15 y and post-pubertal children <15 y with injury severity scores >25. When utilizing pharmacologic prophylaxis, low molecular weight heparin is superior to unfractionated heparin. CONCLUSIONS: While VTE remains an infrequent complication in children, consideration of mechanical and pharmacologic prophylaxis is appropriate in certain populations. TYPE OF STUDY: Systematic Review of level 2-4 studies. LEVEL OF EVIDENCE: Level 3-4.
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OBJECTIVE: Treatment of neonates with anorectal malformations (ARMs) can be challenging due to variability in anatomic definitions, multiple approaches to surgical management, and heterogeneity of reported outcomes. The purpose of this systematic review is to summarize existing evidence, identify treatment controversies, and provide guidelines for perioperative care. METHODS: The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee (OEBP) drafted five consensus-based questions regarding management of children with ARMs. These questions were related to categorization of ARMs and optimal methods and timing of surgical management. A comprehensive search strategy was performed, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform the systematic review to attempt to answer five questions related to surgical care of ARM. RESULTS: A total of 10,843 publications were reviewed, of which 90 were included in final recommendations, and some publications addressed more than one question (question: 1 n = 6, 2 n = 63, n = 15, 4 n = 44). Studies contained largely heterogenous groups of ARMs, making direct comparison for each subtype challenging and therefore, no specific recommendation for optimal surgical approach based on outcomes can be made. Both loop and divided colostomy may be acceptable methods of fecal diversion for patients with a diagnosis of anorectal malformation, however, loop colostomies have higher rates of prolapse in the literature reviewed. In terms of timing of repair, there did not appear to be significant differences in outcomes between early and late repair groups. Clear and uniform definitions are needed in order to ensure similar populations of patients are compared moving forward. Recommendations are provided based primarily on A-D levels of evidence. CONCLUSIONS: Evidence-based best practices for ARMs are lacking for many aspects of care. Multi-institutional registries have made progress to address some of these gaps. Further prospective and comparative studies are needed to improve care and provide consensus guidelines for this complex patient population.
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OBJECTIVE: In 2012, Medicare began cutting reimbursement for hospitals with high readmission rates. We sought to define the incidence and risk factors associated with readmission after surgery. METHODS: A total of 230,864 patients discharged after general, upper gastrointestinal (GI), small and large intestine, hepatopancreatobiliary (HPB), vascular, and thoracic surgery were identified using the 2011 American College of Surgeons National Surgical Quality Improvement Program. Readmission rates and patient characteristics were analyzed. A predictive model for readmission was developed among patients with length of stay (LOS) 10 days or fewer and then validated using separate samples. RESULTS: Median patient age was 56 years; 43% were male, and median American Society of Anesthesiologists (ASA) class was 2 (general surgery: 2; upper GI: 3; small and large intestine: 2; HPB: 3; vascular: 3; thoracic: 3; P < 0.001). The median LOS was 1 day (general surgery: 0; upper GI: 2; small and large intestine: 5; HPB: 6; vascular: 2; thoracic: 4; P < 0.001). Overall 30-day readmission was 7.8% (general surgery: 5.0%; upper GI: 6.9%; small and large intestine: 12.6%; HPB: 15.8%; vascular: 11.9%; thoracic: 11.1%; P < 0.001). Factors strongly associated with readmission included ASA class, albumin less than 3.5, diabetes, inpatient complications, nonelective surgery, discharge to a facility, and the LOS (all P < 0.001). On multivariate analysis, ASA class and the LOS remained most strongly associated with readmission. A simple integer-based score using ASA class and the LOS predicted risk of readmission (area under the receiver operator curve 0.702). CONCLUSIONS: Readmission among patients with the LOS 10 days or fewer occurs at an incidence of at least 5% to 16% across surgical subspecialties. A scoring system on the basis of ASA class and the LOS may help stratify readmission risk to target interventions.
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Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios , Adulto , Idoso , Bases de Dados Factuais , Técnicas de Apoio para a Decisão , Feminino , Seguimentos , Indicadores Básicos de Saúde , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Curva ROC , Análise de Regressão , Fatores de Risco , Procedimentos Cirúrgicos Torácicos , Estados Unidos , Procedimentos Cirúrgicos VascularesRESUMO
We show that single gold nanorods can act as highly sensitive mercury vapor sensors with attogram resolution. We exposed assorted gold nanorods, with aspect ratios ranging from 2.8-4.1, to µg m(-3) concentrations of mercury vapor in air for 1 hour. Pre- and post-exposure, the nanorods were examined with a combination of dark field spectroscopy and transmission electron microscopy. Because we isolated individual particles, we can describe the shape and size effects distinctly rather than statistically (a constraint of studying heterogeneous nanoparticle films). No measurable changes occurred to the shape and size of the nanorods due to their saturation with mercury vapor. The localized surface plasmon resonance (LSPR) of the mercury-saturated nanorods blue shifted 2.6-3.8 nm; the magnitude of the shift depended on the initial shape and size of the nanorod. Larger aspect ratios and surface-area-to-volume ratios both enhance the LSPR shift seen in saturated nanoparticles. The predictions of a core-shell model mirrors the shape and size effects observed experimentally. These results increase our understanding of mercury-adsorption by gold surfaces, and help to optimize nanoparticle-based plasmonic mercury sensing.
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Poluentes Ambientais/análise , Gases/análise , Ouro/química , Mercúrio/análise , Mercúrio/química , Nanopartículas Metálicas/química , Nanotubos/química , Limite de Detecção , Ressonância de Plasmônio de SuperfícieRESUMO
For centuries, scientists have observed nature to understand the laws that govern the physical world. The traditional process of turning observations into physical understanding is slow. Imperfect models are constructed and tested to explain relationships in data. Powerful new algorithms can enable computers to learn physics by observing images and videos. Inspired by this idea, instead of training machine learning models using physical quantities, we used images, that is, pixel information. For this work, and as a proof of concept, the physics of interest are wind-driven spatial patterns. These phenomena include features in Aeolian dunes and volcanic ash deposition, wildfire smoke, and air pollution plumes. We use computer model simulations of spatial deposition patterns to approximate images from a hypothetical imaging device whose outputs are red, green, and blue (RGB) color images with channel values ranging from 0 to 255. In this paper, we explore deep convolutional neural network-based autoencoders to exploit relationships in wind-driven spatial patterns, which commonly occur in geosciences, and reduce their dimensionality. Reducing the data dimension size with an encoder enables training deep, fully connected neural network models linking geographic and meteorological scalar input quantities to the encoded space. Once this is achieved, full spatial patterns are reconstructed using the decoder. We demonstrate this approach on images of spatial deposition from a pollution source, where the encoder compresses the dimensionality to 0.02% of the original size, and the full predictive model performance on test data achieves a normalized root mean squared error of 8%, a figure of merit in space of 94% and a precision-recall area under the curve of 0.93.
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BACKGROUND: Trisomy 13 is a rare genetic condition with a characteristic set of severe congenital abnormalities. Traditionally, the standard of care was to provide palliative care only. However, there has been a recent shift towards life-prolonging care, including surgery. This study seeks to describe surgical outcomes in patients with trisomy 13 and compare them to comorbidity-matched controls. METHODS: Using the ACS NSQIP Pediatric 2012-2019 Participant Use Data Files, patients with trisomy 13 were identified and described. A nearest-neighbor 10:1 propensity score match was performed using demographics, comorbidities, and procedural details. This yielded 254 patients with trisomy 13 and 2,422 controls. Risk ratios for morbidity and mortality by trisomy 13 status were determined using modified Poisson regression. The primary outcomes were thirty-day mortality and the occurrence of any morbidity. RESULTS: The median age of patients with trisomy 13 was 16 months (IQR 87 months). 126 were male (49.6%) and 128 were female (50.4%). There were no differences in overall morbidity compared to controls (31.8% vs. 29.7%, RR 1.06, 95%CI 0.87-1.28, p = 0.554), but patients with trisomy 13 had markedly higher mortality (7.9% vs. 1.8%, RR 4.43, 95%CI 2.28-8.61, p<0.001). CONCLUSIONS: We conclude that patients with trisomy 13 undergoing surgery have frequent morbidity and an elevated although not prohibitive risk of death. Compared to patients with similar comorbidities, they have similar rates of morbidity but a markedly higher risk of mortality. Parents of children with trisomy 13 require thorough counseling on these risks before deciding on surgery.