The Use and Impact of a Decision Support Tool for Appendicitis Treatment.

OBJECTIVE: Since introducing new and alternative treatment options may increase decisional conflict, we aimed to describe the use of the decision support tool (DST) and its impact on treatment preference and decisional conflict. SUMMARY BACKGROUND DATA: For the treatment of appendicitis, antibiotics are an effective alternative to appendectomy, with both approaches associated with a different set of risks (e.g., recurrence vs surgical complications) and benefits (e.g., more rapid return to work vs decreased chance of readmission). Patients often have limited knowledge of these treatment options and decision support tools that include video-based educational materials and questions to elicit patient preferences about outcomes may be helpful. Concurrent to the Comparing Outcomes of Drugs and Appendectomy (CODA) trial, our group developed a DST for appendicitis treatment (www.appyornot.org). METHODS: A retrospective cohort including people who self-reported current appendicitis and used the AppyOrNot DST between 2021-2023. Treatment preferences before- and after- use of the DST, demographic information, and Ottawa Decisional Conflict Scale (DCS) were reported after completing the DST. RESULTS: 8,243 people from 66 countries and all 50 US states accessed the DST. Before the DST, 14% had a strong preference for antibiotics and 31% for appendectomy, with 55% undecided. After using the DST, the proportion in the undecided category decreased to 49% (P<0.0001). 52% of those who completed the Ottawa Decisional Conflict Score (DCS) (n=356) reported the lowest level of decisional conflict (<25) after using the DST; 43% had a DCS score of 25-50, 5.1% had a DCS score of >50 and 2.5% had and DCS score of >75. CONCLUSION: The publicly available DST appyornot.org reduced the proportion that was undecided about which treatment they favored and had a modest influence on those with strong treatment preferences. Decisional conflict was not common after use. The use of this DST is now a component of a nationwide implementation program aimed at improving the way surgeons share information about appendicitis treatment options. If its use can be successfully implemented, this may be a model for improving communication about treatment for patients experiencing emergency health conditions.

PICLN modulates alternative splicing and light/temperature responses in plants.

Plants undergo transcriptome reprograming to adapt to daily and seasonal fluctuations in light and temperature conditions. While most efforts have focused on the role of master transcription factors, the importance of splicing factors modulating these processes is now emerging. Efficient pre-mRNA splicing depends on proper spliceosome assembly, which in plants and animals requires the methylosome complex. Ion Chloride nucleotide-sensitive protein (PICLN) is part of the methylosome complex in both humans and Arabidopsis (Arabidopsis thaliana), and we show here that the human PICLN ortholog rescues phenotypes of Arabidopsis picln mutants. Altered photomorphogenic and photoperiodic responses in Arabidopsis picln mutants are associated with changes in pre-mRNA splicing that partially overlap with those in PROTEIN ARGININE METHYL TRANSFERASE5 (prmt5) mutants. Mammalian PICLN also acts in concert with the Survival Motor Neuron (SMN) complex component GEMIN2 to modulate the late steps of UsnRNP assembly, and many alternative splicing events regulated by PICLN but not PRMT5, the main protein of the methylosome, are controlled by Arabidopsis GEMIN2. As with GEMIN2 and SM PROTEIN E1/PORCUPINE (SME1/PCP), low temperature, which increases PICLN expression, aggravates morphological and molecular defects of picln mutants. Taken together, these results establish a key role for PICLN in the regulation of pre-mRNA splicing and in mediating plant adaptation to daily and seasonal fluctuations in environmental conditions.

Nearly 20 Years Since the Federal Ban: Can State-Level Assault Weapon Prohibitions Fill the Void? Comparative Analysis of Case Fatality and Assault Weapon Recovery in States With and Without an Assault Weapon Ban.

INTRODUCTION: Few states established assault weapon bans (AWBs) after the federal AWB expired. The effectiveness of state AWBs as well as neighboring state legislation, in reducing the local prevalence of assault weapons (AWs) or in reducing overall shooting lethality is unknown. METHODS: We queried the Gun Violence Archive (2014-2021) to identify US firearm injuries and fatalities. Shooting case fatality rates were compared among states with and without AWBs, as reported in the State Firearm Laws Database. Data on recovered firearms was obtained from the ATF Firearms Trace Database and used to estimate weapon prevalence. Recovered firearms were classified as AWs based on caliber (7.62 mm, 5.56 mm, 0.223 cal). We performed spatially weighted linear regression models, with fixed effects for state and year to assess the association between geographically clustered state legislation and firearm outcomes. RESULTS: From 2014 to 2021, the US shooting victim case fatality rate was 8.06% and did not differ among states with and without AWBs. The proportion of AWs to total firearms was 5.0% in states without an AWB and 6.0% in states with an AWB (mean difference [95% CI] = -0.8% [-1.6% to -0.2%], P = 0.03). Most recovered firearms in AWB states originated from non-AWB states. On adjusted models, there was no association between state-level AWB and firearm case fatality; however, adjacency to states with an AWB was associated with lower case fatality (P < 0.001). Clustered AWB states with shared borders had lower AW prevalence and fatality rates than the rest of the US. CONCLUSIONS: Isolated state AWBs are not inversely associated with shooting case fatality rates nor the prevalence of AWs, but AWBs among multiple neighboring states may be associated with both outcomes.

Patients Lost to Follow-up After Injury: Who are They and What are Their Long-Term Outcomes?

INTRODUCTION: Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population. METHODS: Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes. RESULTS: Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012). CONCLUSIONS: Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered.

Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort.

OBJECTIVE: To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days. SUMMARY BACKGROUND DATA: The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes. METHODS: We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations. RESULTS: The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret. CONCLUSIONS: Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02800785.

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

BACKGROUND: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

The Social Vulnerability Index and Long-term Outcomes After Traumatic Injury.

OBJECTIVE: The aim of this study was to evaluate the Social Vulnerability Index (SVI) as a predictor of long-term outcomes after injury. BACKGROUND: The SVI is a measure used in emergency preparedness to identify need for resources in the event of a disaster or hazardous event, ranking each census tract on 15 demographic/social factors. METHODS: Moderate-severely injured adult patients treated at 1 of 3 level-1 trauma centers were prospectively followed 6 to 14 months post-injury. These data were matched at the census tract level with overall SVI percentile rankings. Patients were stratified based on SVI quartiles, with the lowest quartile designated as low SVI, the middle 2 quartiles as average SVI, and the highest quartile as high SVI. Multivariable adjusted regression models were used to assess whether SVI was associated with long-term outcomes after injury. RESULTS: A total of 3153 patients were included [54% male, mean age 61.6 (SD = 21.6)]. The median overall SVI percentile rank was 35th (IQR: 16th-65th). compared to low SVI patients, high SVI patients were more likely to have new functional limitations [odds ratio (OR), 1.51; 95% confidence interval (CI), 1.19-1.92), to not have returned to work (OR, 2.01; 95% CI, 1.40-2.89), and to screen positive for post-traumatic stress disorder (OR, 1.56; 95% CI, 1.12-2.17). Similar results were obtained when comparing average with low SVI patients, with average SVI patients having significantly worse outcomes. CONCLUSIONS: The SVI has potential utility in predicting individuals at higher risk for adverse long-term outcomes after injury. This measure may be a useful needs assessment tool for clinicians and researchers in identifying communities that may benefit most from targeted prevention and intervention efforts.

Social Vulnerability and COVID-19: Changes in Trauma Activations at a Safety-Net Hospital.

INTRODUCTION: Following the declaration of the COVID-19 pandemic, there were reports of decreased trauma hospitalizations, although violent crime persisted. COVID-19 has had the greatest impact on minoritized and vulnerable communities. Decreases in traumatic events may not extend to these communities, given pandemic-related socioeconomic and psychological burdens that increase the risk of exposure to trauma and violence. MATERIALS AND METHODS: This was a retrospective cohort study (n = 1634) of all trauma activations presenting to our institution January 1, 2020 to May 31, 2020, and same time periods in 2018 and 2019. Census tracts and associated Social Vulnerability Index quartiles were determined from patient addresses. Changes in trauma activations pre and post Massachusetts' state-of-emergency declaration compared to a historical control were analyzed using a difference-in-differences methodology. RESULTS: Weekly all-cause trauma activations fell from 26.44 to 8.25 (rate ratio = 0.36 [0.26, 0.50]) postdeclaration, with significant difference-in-differences compared to a historical control (P < 0.0001). Nonviolent trauma activations significantly decreased from 21.11 to 5.17 after the declaration (rate ratio = 0.27 [0.37, 0.91]; P < 0.0001), whereas there was no significant decrease in violent injury (5.33 to 3.08 rate ratio = 0.69 [0.39, 1.22]; P = 0.20). Stratified by vulnerability, the most vulnerable quartile had an increased proportion of all-cause trauma postdeclaration and had no decrease in violent trauma activations following the declaration compared to the historical control (rate ratio = 0.84 [0.38-1.86]; P = 0.67). CONCLUSIONS: The state-of-emergency declaration was associated with significant decreases in overall trauma, to a greater extent in nonviolent injuries. Among those living in the most socially vulnerable communities, there was no decrease in violent trauma. These findings highlight the need for violence and injury prevention programs in vulnerable communities, particularly in times of crisis.

Use and Perceptions of Shared Decision-Making by General Surgery Faculty and Trainees.

INTRODUCTION: The purpose of this study was to assess the practice and perceptions of shared decision-making (SDM) by both faculty and residents at Boston Medical Center and explore barriers and facilitators to implementing SDM at our institution. METHODS: We created and distributed an online survey assessing provider demographic and training characteristics, experiences with the informed consent process, practices in SDM, and perceptions about SDM. We used descriptive statistics to summarize provider characteristics and survey responses and univariate analysis to determine associations between them. RESULTS: Fifteen surgeons and 19 surgical residents completed the survey (49% response rate). Most respondents were aware of and had a positive attitude toward SDM (91% and 76%, respectively); 35% reported having SDM training. Providers had varying levels of engagement with different SDM practices, and there were inconsistent associations between provider characteristics and the use of SDM. Often providers thought the patient's health literacy, foreign primary language, clinical condition, and socioeconomic factors were barriers to the SDM process. CONCLUSIONS: Although most general surgery faculty and residents at our institution had a positive view of SDM, they engaged in SDM behaviors inconsistently, with no clear association between clinician characteristics and specific behaviors. We identified several barriers to SDM consistent with those identified by providers in other specialties. This highlights the need for further research to study live general surgery provider-patient interactions, as well as structured SDM education to train general surgery providers to reliably engage their patients in effective SDM.

Social Vulnerability and Appendicitis: Single-Institution Study in a High Insurance State.

INTRODUCTION: Multiple factors signifying higher social vulnerability, including lower socioeconomic status and minority race, have been associated with presentation with complicated appendicitis (CA). In this study, we compared the Social Vulnerability Index (SVI) of our population by appendicitis severity (uncomplicated appendicitis [UA] versus CA). We hypothesized that SVI would be similar between patients with UA and CA presenting to our institution, a safety-net hospital in a state with high healthcare insurance coverage. METHODS: We included all patients at our hospital aged 18 y and older who underwent appendectomy for acute appendicitis between 2012 and 2016. SVI values were determined based on the 2010 census data using ArcMap software. We used nonparametric univariate statistics to compare the SVI of patients with CA versus UA and multivariable regression to model the likelihood of operative CA. RESULTS: A total of 997 patients met inclusion criteria, of which 177 had CA. The median composite SVI score for patients with CA was lower than for patients with UA (80% versus 83%, P = 0.004). UA was associated with higher socioeconomic (83% versus 80%, P = 0.007), household/disability (68% versus 55%, P = 0.037), and minority/language SVI scores (91% versus 89%, P = 0.037). On multivariable analysis controlling for age, sex, ethnicity, insurance status, relevant comorbidities, and chronicity of symptoms, there was an inverse association between SVI and the likelihood of CA (odds ratio 0.59, 95% confidence interval 0.4-0.87, P = 0.008). CONCLUSIONS: In the setting of high healthcare insurance and a medical center experienced in caring for vulnerable populations, patients presenting with UA have a higher composite SVI, and thus greater social vulnerability, than patients presenting with CA.

Perceived Socioeconomic Status: A Strong Predictor of Long-Term Outcomes After Injury.

BACKGROUND: Socioeconomic status (SES) is defined as a total measure of an individual's economic or social position in relation to others. Income and educational level are often used as quantifiable objective measures of SES but are inherently limited. Perceived SES (p-SES), refers to an individual's perception of their own SES. Herein, we assess the correlation between objective SES (o-SES) as defined by income and educational level and p-SES after injury and compare their associations with long-term outcomes after injury. METHODS: Moderate-to-severely injured patients admitted to a Level 1 trauma center were asked to complete a phone-based survey assessing functional and mental health outcomes, social dysfunction, chronic pain, and return to work/school 6-12 mo postinjury. o-SES was determined by income and educational level (low educational level: high school or lower; low income: live in zip code with median income/household lower than the national median). p-SES was determined by asking patients to categorize their SES. The correlation coefficient between o-SES and p-SES was calculated. Multivariate logistic regression models were built to determine the associations between o-SES and p-SES and long-term outcomes. RESULTS: A total of 729 patients were included in this study. Patients who reported a low p-SES were younger, more likely to suffer penetrating injuries, and to have a weak social support network. Twenty-one percent of patients with high income and high educational level classified their p-SES as low or mid-low, and conversely, 46% of patients with low education and low income classified their p-SES as high or mid-high. The correlation coefficient between p-SES and o-SES was 0.2513. After adjusting for confounders, p-SES was a stronger predictor of long-term outcomes, including functional limitations, social dysfunction, mental health outcomes, return to work/school, and chronic pain than was o-SES. CONCLUSIONS: Patient-reported p-SES correlates poorly with o-SES indicating that the commonly used calculation of income and education may not accurately capture an individuals' SES. Furthermore, we found p-SES to be more strongly correlated with long-term outcome measures than o-SES. As we strive to improve long-term outcomes after injury, p-SES may be an important variable in the early identification of individuals who are likely to suffer from worse long-term outcomes after injury.

Mental Health Burden After Injury: It's About More than Just Posttraumatic Stress Disorder.

OBJECTIVE: Assess the prevalence of anxiety, depression, and posttraumatic stress disorder (PTSD) after injury and their association with long-term functional outcomes. BACKGROUND: Mental health disorders (MHD) after injury have been associated with worse long-term outcomes. However, prior studies almost exclusively focused on PTSD. METHODS: Trauma patients with an injury severity score ≥9 treated at 3 Level-I trauma centers were contacted 6-12 months post-injury to screen for anxiety (generalized anxiety disorder-7), depression (patient health questionnaire-8), PTSD (8Q-PCL-5), pain, and functional outcomes (trauma quality of life instrument, and short-form health survey)). Associations between mental and physical outcomes were established using adjusted multivariable logistic regression models. RESULTS: Of the 531 patients followed, 108 (20%) screened positive for any MHD: of those who screened positive for PTSD (7.9%, N = 42), all had co-morbid depression and/or anxiety. In contrast, 66 patients (12.4%) screened negative for PTSD but positive for depression and/or anxiety. Compared to patients with no MHD, patients who screened positive for PTSD were more likely to have chronic pain {odds ratio (OR): 8.79 [95% confidence interval (CI): 3.21, 24.08]}, functional limitations [OR: 7.99 (95% CI: 3.50, 18.25)] and reduced physical health [ß: -9.3 (95% CI: -13.2, -5.3)]. Similarly, patients who screened positive for depression/anxiety (without PTSD) were more likely to have chronic pain [OR: 5.06 (95% CI: 2.49, 10.46)], functional limitations [OR: 2.20 (95% CI: 1.12, 4.32)] and reduced physical health [ß: -5.1 (95% CI: -8.2, -2.0)] compared to those with no MHD. CONCLUSIONS: The mental health burden after injury is significant and not limited to PTSD. Distinguishing among MHD and identifying symptom-clusters that overlap among these diagnoses, may help stratify risk of poor outcomes, and provide opportunities for more focused screening and treatment interventions.

Impact of the COVID-19 Pandemic on Long-term Recovery From Traumatic Injury.

OBJECTIVE: Determine the proportion and characteristics of traumatic injury survivors who perceive a negative impact of the COVID-19 pandemic on their recovery and to define post-injury outcomes for this cohort. BACKGROUND: The COVID-19 pandemic has precipitated physical, psychological, and social stressors that may create a uniquely difficult recovery and reintegration environment for injured patients. METHODS: Adult (≥18 years) survivors of moderate-to-severe injury completed a survey 6 to 14 months post-injury during the COVID-19 pandemic. This survey queried individuals about the perceived impact of the COVID-19 pandemic on injury recovery and assessed post-injury functional and mental health outcomes. Regression models were built to identify factors associated with a perceived negative impact of the pandemic on injury recovery, and to define the relationship between these perceptions and long-term outcomes. RESULTS: Of 597 eligible trauma survivors who were contacted, 403 (67.5%) completed the survey. Twenty-nine percent reported that the COVID-19 pandemic negatively impacted their recovery and 24% reported difficulty accessing needed healthcare. Younger age, lower perceived-socioeconomic status, extremity injury, and prior psychiatric illness were independently associated with negative perceived impact of the COVID-19 pandemic on injury recovery. In adjusted analyses, patients who reported a negative impact of the pandemic on their recovery were more likely to have new functional limitations, daily pain, lower physical and mental component scores of the Short-Form-12 and to screen positive for PTSD and depression. CONCLUSIONS: The COVID-19 pandemic is negatively impacting the recovery of trauma survivors. It is essential that we recognize the impact of the pandemic on injured patients while focusing on directed efforts to improve the long-term outcomes of this already at-risk population.

COVID-19 Pandemic and the Cholecystitis Experience at a Major Urban Safety-Net Hospital.

BACKGROUND: Acute cholecystitis is a common reason for emergency general surgery admission. The declaration of the COVID-19 pandemic may have resulted in treatment delays and corresponding increases in severity of disease. This study compared cholecystitis admissions and disease severity pre- and postdeclaration of pandemic. MATERIALS AND METHODS: Retrospective review of adult acute cholecystitis admissions (January 1,2020-May 31, 2020). Corresponding time periods in 2018 and 2019 comprised the historical control. Difference-in-differences analysis compared biweekly cholecystitis admissions pre- and postdeclaration in 2020 to the historical control. Odds of increased severity of disease presentation were assessed using multivariable logistic regression. RESULTS: Cholecystitis admissions decreased 48.7% from 5.2 to 2.67 cases (RR 0.51 [0.28,0.96], P = 0.04) following pandemic declaration when comparing 2020 to historical control (P = 0.02). After stratifying by severity, only Tokyo I admissions declined significantly postdeclaration (RR 0.42 [0.18,0.97]), when compared to historical control (P = 0.02). There was no change in odds of presenting with severe disease after the pandemic declaration (aOR 1.00 [95% CI 0.30, 3.38] P < 0.99) despite significantly longer lengths of symptoms reported in mild cases. CONCLUSIONS: Postpandemic declaration we experienced a significant decrease in cholecystitis admissions without corresponding increases in disease severity. The pandemic impacted healthcare-seeking behaviors, with fewer mild presentations. Given that the pandemic did not increase odds of presenting with increased severity of disease, our data suggests that not all mild cases of cholecystitis progress to worsening disease and some may resolve without medical or surgical intervention.

Disparities in Utilization of Ambulatory Cholecystectomy: Results From Three States.

BACKGROUND: Inpatient cholecystectomy is associated with higher cost and morbidity relative to ambulatory cholecystectomy, yet the latter may be underutilized by minority and underinsured patients. The purpose of this study was to examine the effects of race, income, and insurance status on receipt of and outcomes following ambulatory cholecystectomy. MATERIALS AND METHODS: Retrospective observational cohort study of patients 18-89 undergoing cholecystectomy for benign indications in Florida, Iowa, and New York, 2011-2014 using administrative databases. The primary outcome of interest was odds of having ambulatory cholecystectomy; secondary outcomes included intraoperative and postoperative complications, and 30-day unplanned admissions following ambulatory cholecystectomy. RESULTS: Among 321,335 cholecystectomies, 190,734 (59.4%) were ambulatory and 130,601 (40.6%) were inpatient. Adjusting for age, sex, insurance, income, residential location, and comorbidities, the odds of undergoing ambulatory versus inpatient cholecystectomy were significantly lower in black (aOR = 0.71, 95% CI [0.69, 0.73], P< 0.001) and Hispanic (aOR = 0.71, 95% CI [0.69, 0.72], P< 0.001) patients compared to white patients, and significantly lower in Medicare (aOR = 0.77, 95% CI [0.75, 0.80] P < 0.001), Medicaid (aOR = 0.56, 95% CI [0.54, 0.57], P< 0.001) and uninsured/self-pay (aOR = 0.28, 95% CI [0.27, 0.28], P< 0.001) patients relative to privately insured patients. Patients with Medicaid and those classified as self-pay/uninsured had higher odds of postoperative complications and unplanned admission as did patients with Medicare compared to privately insured individuals. CONCLUSIONS: Racial and ethnic minorities and the underinsured have a higher likelihood of receiving inpatient as compared to ambulatory cholecystectomy. The higher incidence of postoperative complications in these patients may be associated with unequal access to ambulatory surgery.

Firearm Policy: Physician Organizations' Role in Political Action Committee Funds, 2018.

Objectives. To compare donations to individual politicians from physician organization political action committees (PACs) and from the National Rifle Association Political Victory Fund (NRA PVF) in 2018.Methods. We identified 7 organizations with published firearm injury prevention policy. We determined the difference in funds received from physician organization PACs and the NRA PVF for each congressmember. We examined their voting records on firearm-related legislation.Results. A total of 141 congressmembers received funds from both physician organization PACs and the NRA PVF. Of these, 99.3% voted for legislation not consistent with organization recommendations. The majority (70.2%) received more funds from the combined physician organization PACs than from the NRA PVF.Conclusions. Physician organization PACs have a financial impact on NRA-backed congressmembers. They currently contribute to politicians with voting records inconsistent with their own policy recommendations. Firearm violence prevention does not currently outweigh other legislative priorities for physician organization PAC contributions.

Educator and Trainee Perspectives on the Need for a "Real World" Curriculum in General Surgery.

BACKGROUND: The necessity of a nonclinical education for surgery residents is a topic of exploration. We examine chief resident (CR) and program director (PD) perspectives on the need for a standardized nonclinical curriculum. METHODS: PDs and CRs from accredited general surgery programs were solicited to partake in an anonymous survey. Data were analyzed using descriptive statistics. RESULTS: There were 42 PD and 68 CR responses. Half or more CRs lack confidence to independently determine their own worth, find a job, negotiate a contract, select disability insurance, and formulate retirement plans. PDs recognize that education in several nonclinical topics is essential for surgical residents. CRs and PDs agree on the necessity for formal education on all topics except "Burnout" (P < 0.0001). CONCLUSIONS: CRs lack the confidence to navigate several nonclinical topics. PDs recognize that education in these topics is necessary. PDs and CRs agree on the need for a nonclinical education except for "Burnout", indicating a positive change in education over time, as most CRs feel they are educated adequately on this topic. Validation of a uniform curriculum is needed.

The Association of Primary Language With Emergency General Surgery Outcomes Using a Statewide Database.

BACKGROUND: Emergency general surgery (EGS) represents a diverse set of operations performed on acutely ill patients. Those undergoing EGS are at higher likelihood of complications, readmission, and death, but the effect of primary language on EGS outcomes has not been evaluated. We aimed to evaluate the association of non-English primary language on outcomes after EGS operations. METHODS: The New Jersey Statewide Inpatient Database from 2009 to 2014 was used to evaluate cases representing 80% of the national burden of EGS. Cases were restricted to ages ≥18 y, emergency department admissions, noted to be emergent or urgent, and performed between 0 and 2 d after admission. We evaluated Spanish speakers and non-English, non-Spanish (NENS) speakers compared with English. Outcomes included in-hospital mortality, 7-d readmission, and hospital length of stay (LOS). Logistic and negative binomial regression was used, and generalized linear mixed models were used to account for hierarchy in the data. RESULTS: There were 105,171 patients included. English speakers were majority white and with private insurance; Spanish speakers were younger and with fewer comorbidities. Where differences between Spanish and NENS speakers existed, NENS were more like the English-speaking group. Adjusted results indicate that Spanish speakers had reduced LOS after appendectomy (IRR: 0.92 [0.89-0.95]) and lysis of adhesion [0.93 (0.88-0.97)]. Spanish speakers had an increased LOS after higher risk operations (IRR: 1.14 [1.10-1.20]). NENS speakers had a reduced LOS after adhesiolysis (IRR: 0.94 [0.89-0.99]). There was no difference in mortality or short-term readmission CONCLUSIONS: These data from a large database suggest that the effect of primary language on LOS after EGS depends on the type of operation. Future studies should focus on long-term outcomes and determining if the lack of association we observed is generalizable to other regions of the United States.

The spliceosome assembly factor GEMIN2 attenuates the effects of temperature on alternative splicing and circadian rhythms.

The mechanisms by which poikilothermic organisms ensure that biological processes are robust to temperature changes are largely unknown. Temperature compensation, the ability of circadian rhythms to maintain a relatively constant period over the broad range of temperatures resulting from seasonal fluctuations in environmental conditions, is a defining property of circadian networks. Temperature affects the alternative splicing (AS) of several clock genes in fungi, plants, and flies, but the splicing factors that modulate these effects to ensure clock accuracy throughout the year remain to be identified. Here we show that GEMIN2, a spliceosomal small nuclear ribonucleoprotein assembly factor conserved from yeast to humans, modulates low temperature effects on a large subset of pre-mRNA splicing events. In particular, GEMIN2 controls the AS of several clock genes and attenuates the effects of temperature on the circadian period in Arabidopsis thaliana. We conclude that GEMIN2 is a key component of a posttranscriptional regulatory mechanism that ensures the appropriate acclimation of plants to daily and seasonal changes in temperature conditions.