Difference in Postoperative Outcomes and Perioperative Resource Utilization Between General Surgeons and Pediatric Surgeons: A Systematic Review.

Background: Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes based on surgeon training. We performed a systematic review and meta-analysis to compare postoperative outcomes and perioperative resource utilization for pediatric appendectomies.Methods: We searched PubMed to identify articles examining the association between surgeon specialization and outcomes for pediatric patients undergoing appendectomies. Study selection, data extraction, risk of bias assessment, and quality assessment were performed by one reviewer, with another reviewer to resolve discrepancies.Results: We identified 4799 articles, with 98.4% (4724/2799) concordance after initial review. Following resolution of discrepancies, 16 studies met inclusion criteria. Of the studies that reported each outcome, GS and PS demonstrated similar rates of readmission within 30 days (pooled RR 1.61 95% CI 0.66, 2.55) wound infections (pooled RR 1.07, 95% CI .55, 1.60), use of laparoscopic surgery (pooled RR 1.87, 95% CI .21, 3.53), postoperative complications (pooled RR 1.40, 95% CI .83, 1.97), use of preoperative imaging (pooled RR .98,95% CI .90, 1.05), and intra-abdominal abscesses (pooled RR .80, 95% CI .03, 1.58). Patients treated by GS did have a significantly higher risk of negative appendectomies (pooled RR 1.47, 95% CI 1.10, 1.84) when compared to PS.Discussion: This is the first meta-analysis to compare outcomes for pediatric appendectomies performed by GS compared to PS. Patient outcomes and resource utilization were similar among PS and GS, except for negative appendectomies were significantly more likely with GS.

Injury Patterns, Imaging Usage, and Disparities Associated With Car Restraint Use in Children.

BACKGROUND: Motor vehicle collision (MVC) is a leading cause of accidental death in children. Despite effective forms of child safety restraint (eg, car seat and booster seat), studies demonstrate poor compliance with guidelines. The goal of this study was to delineate injury patterns, imaging usage, and potential demographic disparities associated with child restraint use following MVC. METHODS: A retrospective review of the North Carolina Trauma Registry was performed to determine demographic factors and outcomes associated with improper restraint of children (0-8 years) involved in MVC from 2013 to 2018. Bivariate analysis was performed by the appropriateness of restraint. Multivariable Poisson regression identified demographic factors for the relative risk of inappropriate restraint. RESULTS: Inappropriately restrained patients were older (5.1 years v. 3.6 yrs, P < .001) and weighed more (44.1 lbs v. 35.3 lbs, P < .001). A higher proportion of African American (56.9% v. 39.3%, P < .001) and Medicaid (52.2% v. 39.0%, P < .001) patients were inappropriately restrained. Multivariable Poisson regression showed that African American patients (RR 1.43), Asian patients (RR 1.51), and Medicaid payor status (RR 1.25) were associated with a higher risk of inappropriate restraint. Inappropriately restrained patients had a longer length of stay, but injury severity score and mortality were no different. DISCUSSION: African American children, Asian children, and Medicaid insurance payor status patients had an increased risk of inappropriate restraint use in MVC. This study describes unequal restraint patterns in children, which suggests opportunity for targeted patient education and necessitates research to further delineate the underlying etiology of these differences.

The Effect of an Enhanced Recovery Protocol on Pediatric Colorectal Surgical Patient Outcomes at a Single Institution.

INTRODUCTION: Enhanced recovery protocols (ERP) have been associated with fewer postoperative complications in adult colorectal surgery patients, but there is a paucity of data on pediatric patients. Our aim is to describe the effect of an ERP, compared to conventional care, on pediatric colorectal surgical complications. MATERIALS AND METHODS: We performed a single institution, retrospective cohort study (2014-2020) on pediatric (≤18 years old) colorectal surgery patients pre- and post-implementation of an ERP. Bivariate analysis and logistic regression were used to assess the effect of an ERP on return visits to the emergency room, reoperation, and readmission within 30-days. RESULTS: There were 194 patients included in this study, with 54 in the control cohort and 140 in the ERP cohort. There was no significant difference in the age, BMI, primary diagnosis, or use of laparoscopic technique between the cohorts. The ERP cohort had a significantly shorter foley duration, postoperative stay, and had nerve blocks performed. After controlling for pertinent covariates, the ERP cohort experienced higher odds of reoperation within 30 days (OR 5.83, P = .04). There was no significant difference in the other outcomes analyzed. CONCLUSION: In this study, there was no difference in the odds of overall complications, readmission or return to the ER within 30-days of surgery. However, although infrequent, there were higher odds of returns to the OR within 30 days. Future studies are needed to analyze how adherence to individual components may influence patient outcomes to ensure patient safety during ERP implementation.

Sex-Based Differences in Survival Among Patients with Acute Abdomen Undergoing Surgery in Malawi: A Propensity Weighted Analysis.

INTRODUCTION: Sex disparities in access to health care in low-resource settings have been demonstrated. Still, there has been little research on the effect of sex on postoperative outcomes. We evaluated the relationship between sex and mortality after emergency abdominal surgery. METHODS: We performed a retrospective cohort study using the acute care surgery database at Kamuzu Central Hospital (KCH) in Malawi. We included patients who underwent emergency abdominal surgery between 2013 and 2021. We created a propensity score weighted Cox proportional hazards model to assess the relationship between sex and inpatient survival. RESULTS: We included 2052 patients in the study, and 76% were males. The most common admission diagnosis in both groups was bowel obstruction. Females had a higher admission shock index than males (0.91 vs. 0.81, p < 0.001) and a longer delay from admission until surgery (1.47 vs. 0.79 days, p < 0.001). Females and males had similar crude postoperative mortality (16.3% vs. 15.3%, p = 0.621). The final Cox proportional hazards regression model was based on the propensity-weighted cohort. The mortality hazard ratio was 0.65 among females compared to males (95% CI 0.46-0.92, p = 0.014). CONCLUSIONS: Our results show a survival advantage among female patients undergoing emergency abdominal surgery despite sex-based disparities in access to surgical care that favors males. Further research is needed to understand the mechanisms underlying these findings.

Cholecystectomies performed in children by pediatric surgeons compared to general surgeons in North Carolina are associated with higher institutional charges.

INTRODUCTION: The delivery of pediatric surgical care for gallbladder (GB) and biliary disease involves both General Surgeons (GS) and Pediatric Surgeons (PS). There is a lack of data describing how surgeon specialty impacts practice patterns and healthcare charges. METHODS: We performed a retrospective review of the North Carolina Inpatient Hospital Discharge Database (2013-2017) on pediatric patients (≤18 years) undergoing surgery for biliary pathology. We performed multivariate linear regression comparing surgeons with surgical charge. RESULTS: 12,531 patients had GB or biliary pathology and 4023 (32.1%) had cholecystectomies. The most common procedure for PS and GS was cholecystectomy for cholecystitis (n = 509, 54.0% and n = 2275, 76.4%, p < 0.001), respectively. The hospital ($26,605, IQR $18,955-37,249, vs. $17,451, IQR $13,246-23,478, p < 0.001) and surgical charges ($15,465, IQR $12,233-22,203, vs. $10,338, IQR $6837-14,952, p < 0.001) were higher for PS than GS. Controlling for pertinent variables, surgical charges for PS were $4192 higher than for GS (95% CI: $2162-6122). CONCLUSION: The cholecystectomy charge differential between PS and GS is significant and persisted after controlling for pertinent covariates.

Reasons for in-hospital delays to emergency surgical care in a resource-limited setting: Surgery versus anesthesiology perspective.

Patients experience delays in emergency surgical care. Our 3-month mixed-methods observational prospective study examined the duration of in-hospital delays (IHDs) to emergency surgery at a tertiary hospital in Malawi and perceived reasons for such delay, assessing the correlation between surgery and anesthesia. Delays over two hours occurred in the majority, and almost 20% waited over twelve hours. However, we found no correlation between surgeons and anaesthetists in the perceived reasons for In-hospital delays to emergency surgical care.

Acute care surgery in a Malawian district hospital: Epidemiology, outcomes, and assessment of operative capacity.

District hospitals (DHs) care for the majority of surgical patients in Malawi, but data on district hospital surgical capacity are limited. We sought to evaluate the management and outcomes of surgical patients presenting to Salima District Hospital (SDH) in Malawi. Using the SDH surgery registry, we compared patients managed operatively and those non-operatively and performed logistic regression to identify factors associated with operative management. We then compared cases performed at SDH with procedures recommended to be performed at DHs. We included 1374 patients, of whom half were managed operatively. The most common procedures performed were abscess drainage and wound debridement. Logistic regression analysis revealed that patients with abdominal diagnoses were least likely to be treated operatively. Though SDH performs most procedures recommended for the district hospital level, patients requiring laparotomies were most likely to be transferred to a referral hospital. Future studies should assess barriers to performing laparotomies at SDH.

Appendectomy by Pediatric Surgeons in North Carolina is Associated With Higher Charge Than General Surgeons.

INTRODUCTION: The delivery of pediatric surgical care for acute appendicitis involves general surgeons (GS) and pediatric surgeons (PS), but the differences in clinical practice are primarily undescribed. We examined charge differences between GS and PS for the treatment of pediatric acute appendicitis. METHODS: We performed a retrospective review of the North Carolina hospital discharge database (2013-2017) in pediatric patients (≤18 y) who had surgery for appendiceal pathology (acute or chronic appendicitis and other appendiceal pathology). We performed a bivariate analysis of surgical charges over the type of surgical providers (GS, PS, other specialty, and unassigned surgeons). RESULTS: Over the study period, 21,049 patients had appendicitis or other diseases of the appendix, and 15,230 (72.4%) underwent appendectomy. Patients who were operated on by PS were younger (10 y, interquartile range (IQR): 6-13 versus 13 y, IQR: 9-16, P < 0.001). Acute appendicitis was diagnosed in 2860 (44.3%) and 3173 (49.2%) of the PS and GS cohorts, respectively, P = 0.008. PS compared to GS performed a higher percentage of laparoscopic (n = 2,697, 89.4% versus n = 2,178, 65.5%) than open appendectomies (n = 280, 9.3% versus n = 1,118, 33.6%), P < 0.001. The overall hospital charges were $28,081 (IQR: $21,706-$37,431) and $24,322 (IQR: $17,906-$32,226) for PS and GS, respectively, P < 0.001. Surgical charges where higher for PS than GS, $12,566 (IQR: $9802-$17,462) and $8051 (IQR: $5872-$2331), respectively. When controlling for diagnosis, surgical approach, emergent status, age, and surgical cost of appendiceal surgery, and hospital charges following appendiceal surgery were $4280 higher for PS than GS (95% CI: 3874-4687). CONCLUSIONS: The total charge for operations for appendiceal disease is significantly higher for PS compared to GS. Pediatric surgeons had increased surgical charges compared to GS but decreased radiology charges. The specific reasons for these differences are not clearly delineated in this data set and persist after controlling for relevant covariates. However, these data demonstrate that increasing value in pediatric appendicitis may require specialty-based targets.

Malawi Trauma Score is Predictive of Mortality at a District Hospital: A Validation Study.

BACKGROUND: Trauma scoring systems can identify patients who should be transferred to referral hospitals, but their utility in LMICs is often limited. The Malawi Trauma Score (MTS) reliably predicts mortality at referral hospitals but has not been studied at district hospitals. We sought to validate the MTS at a Malawi district hospital and evaluate whether MTS is predictive of transfer to a referral hospital. METHODS: We performed a retrospective study using trauma registry data from Salima District Hospital (SDH) from 2017 to 2021. We excluded patients brought in dead, discharged from the Casualty Department, or missing data needed to calculate MTS. We used logistic regression modeling to study the relationship between MTS and mortality at SDH and between MTS and transfer to a referral hospital. We used receiver operating characteristic analysis to validate the MTS as a predictor of mortality. RESULTS: We included 2196 patients (84.3% discharged, 12.7% transferred, 3.0% died). These groups had similar ages, sex, and admission vitals. Mean (SD) MTS was 7.9(3.0) among discharged patients, 8.4(3.9) among transferred patients, and 14.2(8.0) among patients who died (p < 0.001). Higher MTS was associated with increased odds of mortality at SDH (OR 1.21, 95% CI 1.14-1.29, p < 0.001) but was not related to transfer. ROC area for mortality was 0.73 (95% CI 0.65-0.80). CONCLUSIONS: MTS is predictive of district hospital mortality but not inter-facility transfer. We suggest that MTS be used to identify patients with severe trauma who are most likely to benefit from transfer to a referral hospital.

The effect of COVID-19 on burn management and outcomes in a resource-limited setting.

INTRODUCTION: Optimal burn care includes fluid resuscitation and early excision and grafting. During the COVID-19 pandemic, resource-constrained environments were susceptible to interruptions in burn care. We sought to characterize pre- and intra-pandemic burn-associated outcomes at a busy tertiary hospital in Malawi. METHODS: This is a retrospective analysis of burn patients that presented to Kamuzu Central Hospital Lilongwe from 2011 through December 2021. We compared patients based on whether they presented pre- or intra-pandemic, starting on March 11, 2020, the date of official WHO designation. Comparing these cohorts, we used modified Poisson modeling to estimate the adjusted risk of undergoing an operation and the risk of death. RESULTS: We included 2969 patients, with 390 presenting during the pandemic. Patient factors were similar between the cohorts. More patients underwent surgery pre-pandemic (21.1 vs 10.3 %, p < 0.001) but crude mortality was similar at 17.3 % vs. 21.2 % (p = 0.08). The RR of undergoing surgery during the pandemic was 0.45 (95 % CI 0.32, 0.64) adjusted for age, sex, % TBSA, flame burns, and time to presentation. During the pandemic, the risk ratio for in-hospital mortality was 1.23 (95 % CI 1.01, 1.50) adjusted for age, sex, % TBSA, surgical intervention, flame burns, and time to presentation. CONCLUSIONS: During the pandemic, the probability of undergoing burn excision or grafting was significantly lower for patients, independent of the severity. Consequently, the adjusted risk of mortality was higher. To improve patient outcomes, efforts to preserve operative capacity for burn patients during periods of severe resource constraint are imperative.

Reallocation of Hospital Resources During COVID-19 Pandemic and Effect on Trauma Outcomes in a Resource-Limited Setting.

BACKGROUND: The COVID-19 pandemic has caused unprecedented disruptions to surgical care worldwide, particularly in low-resource countries. We sought to characterize the association between pre-and intra-pandemic trauma clinical outcomes at a busy tertiary hospital in Malawi. METHODS: We analyzed trauma patients that presented to Kamuzu Central Hospital in Lilongwe, Malawi, from 2011 through July 2021. Burn patients were excluded. We compared patients based on whether they presented before or during the pandemic (defined as starting March 11, 2020, the date of the official WHO designation). We used logistic regression modeling to estimate the adjusted odds ratio of death based on presentation. RESULTS: A total of 137,867 patients presented during the study period, with 13,526 patients during the pandemic. During the pandemic, patients were more likely to be older (mean 28 vs. 25 years, p < 0.001), male (79 vs. 74%, p < 0.001), and suffer a traumatic brain injury (TBI) as their primary injury (9.7 vs. 4.9%, p < 0.001). Crude trauma-associated mortality was higher during the pandemic at 3.7% vs. 2.1% (p < 0.001). The odds ratio of mortality during the pandemic compared to pre-pandemic presentation was 1.28 (95% CI 1.06, 1.53) adjusted for age, sex, initial AVPU score, transfer status, injury type, and mechanism. CONCLUSIONS: During the pandemic, adjusted trauma-associated mortality significantly increased at a tertiary trauma center in a low-resource setting despite decreasing patient volume. Further research is urgently needed to prepare for future pandemics. Potential targets for improvement include improving pre-hospital care and transportation, planning for intensive care utilization, and addressing nursing shortages.

Failure to thrive, oral intake, and inpatient status prior to gastrostomy tube placement in the first year of life is associated with persistent use 1-year later.

BACKGROUND: Gastrostomy tube (GT) placement is a common procedure in infants (≤1-year-old). There is variation in patient selection and a paucity of studies examining which patients require long term enteral access. The objective of this study was to assess demographic and clinical factors associated with persistent GT use (PGU) at 1-year after placement. METHODS: We performed a single-institution retrospective review of patients ≤1-year-old who underwent GT placement from January 31, 2014, and January 31, 2020, using institutional NSQIP-P data supplemented with chart review. Multivariable logistic regression analysis was performed to identify factors associated with PGU. Clinical predictors were selected a priori, and a p-value less than 0.05 was used to detect a significant association. RESULTS: 140 patients were included, and 118 had a 1-year follow-up. At 1-year following GT placement, 38 patients had weaned from their GT (32.2%). Failure to thrive (FTT), and inpatient admission prior to surgery are associated with increased odds of PGU at 1-year after surgery, OR: 5.19 and 6.02, respectively. There is an inverse association between the percentage of feeds taken by mouth at the time of surgery and the odds of PGU at 1-year (OR: 0.03). CONCLUSION: Patients who have FTT (documented prior to surgery) or an inpatient admission prior to GT had a higher odds of PGU at 1-year post-op. Additionally, the amount taken by mouth at the time of GT placement was inversely related to PGU. These factors are important in determining the need for a surgical gastrostomy tube. LEVEL OF EVIDENCE: II.

Direct Transfer to a Tertiary Care Hospital After Traumatic Injury is Associated with a Survival Benefit in a Resource-Limited Setting.

INTRODUCTION: Trauma is a leading cause of morbidity and mortality worldwide, and patients in low- and middle-income countries are disproportionately affected. Organized trauma systems, including appropriate transfer to a higher level of care, improve trauma outcomes. We sought to evaluate the relationship between transfer status and trauma mortality in Malawi. METHODS: We performed a retrospective analysis of trauma patients admitted to Kamuzu Central Hospital (KCH), a trauma center in Lilongwe, Malawi, between January 1, 2013, and May 30, 2018. Transfer status was categorized as direct if a patient arrives at KCH from the injury scene and indirect if a patient comes to KCH from another health care facility. We used logistic regression modeling to evaluate the relationship between transfer status and in-hospital mortality. RESULTS: A total of 8369 patients were included in the study. The mean age was 34.6 years (SD 15.8), and 81% of patients were male. The most common mechanism of injury was motor vehicle collision. Injury severity did not significantly differ between the two groups. Crude mortality was 4.8% for indirect and 2.6% for direct transfers. After adjusting for relevant covariates, odds ratio of mortality was 2.12 (1.49-3.02, p < 0.001) for indirect versus direct transfers. CONCLUSION: Trauma patients indirectly transferred to a trauma center have nearly double the risk of mortality compared to direct transfers. Trauma outcome improvement efforts must focus on strengthening prehospital care, improving district hospital capacity, and developing protocols for early assessment, treatment, and transfer of trauma patients to a trauma center.

Cultural Competence, Safety, Humility, and Dexterity in Surgery.

PURPOSE OF REVIEW: As the United States' population diversifies, urgent action is required to identify, dismantle, and eradicate persistent health disparities. The surgical community must recognize how patients' values, beliefs, and behaviors are influenced by race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation, and occupation. RECENT FINDINGS: Lately, health disparities have been highlighted during the COVID-19 pandemic. Surgery is no exception, with notable disparities occurring in pediatric, vascular, trauma, and cardiac surgery. In response, numerous curricula and training programs are being designed to increase cultural competence and safety among surgeons. SUMMARY: Cultural competence, safety, humility, and dexterity are required to improve healthcare experiences and outcomes for minorities. Various opportunities exist to enhance cultural competency and can be implemented at the medical student, resident, attending, management, and leadership levels.

Analysis of a Modified Two-Stage Approach to Ileal Pouch-Anal Anastomosis Without Fecal Diversion in Pediatric Patients.

BACKGROUND: Fecal diversion after ileal pouch anal anastomosis (IPAA) in children with ulcerative colitis (UC) remains controversial. We hypothesize that a modified two-stage IPAA omitting diverting ileostomy (DI) after IPAA, found to be safe in adults, would produce similar results in children. METHODS: Retrospective, single-institution study of children (≤18 years) undergoing staged total proctocolectomy with IPAA from 2014 to 2020. Traditional two-stage and three-stage approaches including DI after IPAA were compared to two-stage approach without DI. RESULTS: 32 patients were included; of these, 7 (22%), 14 (44%), and 11 (34%) patients underwent traditional two-stage, modified two-stage, or three-stage IPAA, respectively. Following IPAA, modified two-stage patients had shorter operative time, decreased opioid utilization, quicker return to regular diet, and shorter stoma duration. After IPAA, there was similar postoperative length of stay, complication rates, readmissions, visits to the emergency department, or unplanned return to the operating room (OR) within 30 days. Anastomotic leak occurred in 2 patients; both were managed nonoperatively without evidence of pouch dysfunction. CONCLUSION: Modified two-stage IPAA with omission of DI after the IPAA stage is safe to perform in pediatric UC patients. Prospective studies with larger sample sizes are needed to identify risk factors associated with operative complications.

A Comparison of Adult and Pediatric Enhanced Recovery after Surgery Pathways: A Move for Standardization.

BACKGROUND: Enhanced recovery protocols (ERP) are a multimodal approach to standardize perioperative care. To substantiate the benefit of a pediatric-centered pathway, we compared outcomes of children treated with pediatric ERP (pERP) versus adult (aERP) pathways. We aimed to compare components of each pathway to create a new comprehensive pERP to reduce variation in care. METHODS: Retrospective study of children (≤18 y) undergoing elective colorectal surgery from August 2015 to April 2019 at a single institution managed with pERP versus aERP. Multivariable linear and logistic regression, adjusting for demographics and operation characteristics, were used to compare outcomes. RESULTS: Out of 100 hospitalizations (72 patients) were identified, including 37 treated with pERP. pERP patients were, on average, younger (13 versus 16 y), more likely to be ASA III (70% versus 30%), and more likely to receive regional (32% versus 3%) or neuraxial (35% versus 8%) anesthesia. Epidural use was an independent risk factor for longer length of stay (P = 0.000). After adjustment, pERP patients had similar LOS and time to oral intake, but shorter foley duration. pERP patients used significantly fewer opioids and were less likely to return to the operating room within 30 d. 30-d readmissions and ED visits were also lower, but this was not statistically significant. CONCLUSIONS: At our institution, data from both ERPs contributed formation of a synthesized pathway and reflected the pERP approach to opioid utilization and the aERP approach to earlier enteral nutrition.

Risk of acute kidney injury requiring hemodialysis after contrast-enhanced imaging after traumatic injury: A National Trauma Databank analysis.

BACKGROUND: Trauma patients undergo routine contrast administration for diagnostic and therapeutic purposes. The aim of this study is to investigate the incidence and predictors of contrast-induced nephropathy requiring acute hemodialysis in the trauma population. METHODS: Adult patients (age ≥16) were identified from the National Trauma Databank (2017-2018) and were grouped based on contrast received. The defined groups included no contrast, computed tomography intravascular contrast only, and angiography contrast. Patient demographic and clinical variables collected included vital signs (systolic blood pressure, pulse rate) recorded upon arrival to the emergency room, injury severity score, shock index, Glasgow Coma Scale, and mechanism. Outcome measures included mortality, hospital discharge disposition, intensive care unit and hospital length of stay, and need for hemodialysis. We performed a Poisson regression to assess relative risk for undergoing hemodialysis during hospital admission. RESULTS: In total, 1,850,460 patients were included in the analysis (no contrast: 1,189,209; computed tomography intravascular contrast only: 621,846; angiography: 39,405); 3,135 patients required hemodialysis during the admission. Patients with reduced Glasgow Coma Scale, higher injury severity score, higher shock index, and preexisting diabetes mellitus and hypertension were more likely to require hemodialysis. Poisson regression revealed the relative risk of requiring hemodialysis as 1.49 with computed tomography intravascular contrast only, 4.33 with angiography only, and 5.35 with consecutive computed tomography intravascular and angiography. CONCLUSION: Intravascular contrast administration through computed tomography and or angiography is independently associated with increased risk of requiring hemodialysis after a traumatic injury. Trauma surgeons should consider the necessity of contrast for each clinical situation and understand the potential for contrast-induced nephropathy.

The Impact of General Surgeons on Pediatric Surgical Practice in North Carolina: The Reality of Pediatric Surgical Care Delivery.

OBJECTIVE: The aim of this study was to define the training background of the actual surgical workforce providing care to pediatric patients in North Carolina (NC). BACKGROUND: Due to database limitations, pediatric surgical workforce studies have not included general surgeons (GS) who operate on children. Defining the role of GS in care delivery affects policy for clinical care and general and pediatric surgical training. METHODS: We performed a retrospective review of the NC Hospital Discharge Database (2011-2017), including pediatric patients (<18 years) undergoing the most frequent general surgery procedures. Descriptive and correlational analysis over surgical provider [Pediatric Surgeon (PS), GS], and other specialties (OSS), was performed using logistic regression modeling to identify factors associated with surgery by a PS. RESULTS: Of the 57,265 discharges analyzed, pediatric, general, and other specialty surgeons operated on 25,514 (44.6%), 18,581 (32.5%), and 9049 (15.8%), respectively. In a logistic regression model, PS had lower odds of operating on older patients [odds ratio (OR) 0.9, 95% confidence interval (CI) 0.90-0.91]. However, PS were more likely to operate on female patients (OR 1.58, 95% CI 1.53-1.65), Black (OR 1.49, 95% CI 1.43-1.56), and other minority patients (OR 1.23, 95% CI 1.17-1.29) when compared to white patients. PS were also more likely to operate on patients with private insurance (OR 1.38, 95% CI 1.33-1.43) compared to government insurance, and patients undergoing emergency surgery (OR 1.44, 95% CI 1.38-1.50). CONCLUSION: In NC, general surgeons performed a third of the operations on children. After controlling for covariates, pediatric surgeons in NC are more likely to operate on minority and emergency surgery patients, and this is the first study to describe this important practice pattern.

Characteristics and predictors of mortality in-hospital mortality following burn injury in infants in a resource-limited setting.

PURPOSE: Burn outcome data in infants is lacking from sub-Saharan Africa. We, therefore, sought to assess the characteristics and predictors of in-hospital burn mortality in a resource-limited setting. METHODS: We performed a retrospective study of the prospectively collected Burn Injury Surveillance database from June 2011 to December 2019. We performed bivariate analysis and Poisson regression to assess risk factors for mortality in our infant burn population. RESULTS: 115 (7.3%) infants met inclusion criteria. The median age of 8 months (IQR: 6-10) and primarily male (n = 67, 58.8%). Most burns were from scald (n = 62, 53.9%). Infant burn mortality was 12.2%. Poisson multivariable regression to determine burn mortality risk in infants showed that increased %TBSA burns (RR 1.04, 95% CI 1.01-1.07) and flame burns (RR 3.08, 95%CI 1.16-8.16) had a higher risk of mortality. Having surgery reduced the relative risk of death for infants with burns. CONCLUSION: We show that factors that increase infant burn mortality risk include percent total body surface area burn, flame burn mechanism, and lack of operative intervention. Increasing burn operative capability, particularly for infants and other children, is imperative.