Optimizing Triage Practice in Pediatric Trauma: Lessons From Under-triage and Over-triage Rates and Risk Factors.

BACKGROUND: Triage accuracy is essential for delivering effective trauma care, especially in the pediatric population where unique challenges exist. The purpose of this study was to investigate risk factors contributing to under-triage and over-triage in an urban pediatric trauma center. METHODS: This retrospective cohort study included all trauma activations at an urban level 1 trauma center between January 1, 2021, and July 31, 2023 (patients <18 years old.) Patients who were under- or over-triaged were identified based on the level of trauma activation and injury severity score. RESULTS: There were 1094 trauma activations included in this study. The rate of under-triage was 3.8% (n = 42) and over-triage was 13.6% (n = 149). Infants aged 0-1 years had the highest rate of under-triage (10.9%, n = 19, P < .001), while those aged 11-17 had the highest rate of over-triage (17.0%, n = 82, P = .003). Non-accidental trauma was the strongest risk factor for under-triage (OR 30.2 [6.4-142.8] P < .001). Penetrating mechanism was the strongest risk factor for over-triage (OR 12.2 [5.6-26.2] P < .001). DISCUSSION: This study reveals the complexity of trauma triage in the pediatric population. We identified key predictive factors, such as age, comorbidities, and mechanism of injury, that can be used to refine triage practices and improve the care of pediatric trauma patients.

Impact of Minimally Invasive Approach on Attainment of a Textbook Oncologic Outcome Following Gastrectomy for Gastric Cancer: A Review of the National Cancer Database.

BACKGROUND: Textbook oncologic outcome (TOO) is a composite outcome measure realized when all desired short-term quality metrics are met following an oncologic operation. This study examined whether minimally invasive gastrectomy (MIG) is associated with increased likelihood of TOO attainment. METHODS: The 2010-2016 National Cancer Database was queried for patients with gastric cancer who underwent gastrectomy. Surgical approach was described as open (OG), laparoscopic (LG), or robotic (RG). TOO was defined as having met five metrics: R0 resection, AJCC compliant lymph node evaluation (n ≥ 15), no prolonged length of stay (< 75th percentile by year), no 30-day readmission, and receipt of guideline-accordant systemic therapy. RESULTS: Of 21,015 patients identified, 5708 (27.2%) underwent MIG (LG = 21.9%, RG = 5.3%). Patients who underwent RG were more likely to have met all TOO criteria, and consequently TOO. Logistic regression models revealed that patients undergoing MIG were significantly more likely to attain TOO. MIG was associated with a higher likelihood of adequate LAD, no prolonged LOS, and concordant chemotherapy. Patients who underwent LG and achieved TOO had the highest median OS (86.7 months), while the OG non-TOO cohort experienced the lowest (34.6 months). The median OS for the RG TOO group was not estimable; however, the mortality rate (.7%) was the lowest of the six cohorts. CONCLUSION: RG resulted in a significantly increased likelihood of TOO attainment. Although TOO is associated with increased OS across all surgical approaches, attainment of TOO following MIG is associated with a statistically significantly higher median OS.

Impact of Textbook Oncologic Outcome Attainment on Survival After Gastrectomy: A Review of the National Cancer Database.

BACKGROUND: Textbook oncologic outcome (TOO) is a composite outcome measure realized when all desired short-term quality metrics are met after an oncologic operation. This study examined the incidence and impact of achieving a TOO among patients undergoing resection of gastric adenocarcinoma. METHODS: The 2004-2016 National Cancer Database was queried for patients who underwent curative gastrectomy. Textbook oncologic outcome was defined as having met five metrics: R0 resection, American Joint Committee on Cancer-compliant lymph node evaluation (n ≥ 15), no prolonged hospital stay (< 75th percentile by year), no 30-day readmission, and receipt of guideline-accordant systemic therapy. RESULTS: Of 34,688 patients identified, 8249 (23.8 %) achieved TOO. The patients for whom TOO was achieved were more likely to have traveled farther (p < 0.001) and received care in an academic (p < 0.001) or very high case-volume facility (p < 0.001). The TOO group had a significanty higher median overall survival (OS) than the non-TOO group (80.5 vs 35.3 months; p < 0.001). The Kaplan-Meier curve showed that at 12 months, the survival probability estimate was 92 % for the TOO group versus 77 % for the non-TOO group. At 60 months (long-term survival), survival probability estimates remained higher for the TOO group (57 % vs 38 %). The results of the multivariate Cox regression model found that TOO attainment was significantly associated with a reduced risk of death (hazard ratio, 0.82; p < 0.001). CONCLUSION: The TOO measure is associated with improved OS and reduced risk of death after gastrectomy for gastric adenocarcinoma. Unfortunately, in this study, TOO was obtained in only 23.8 % of cases.

MANAGEMENT OF HYPERPARATHYROIDISM IN KIDNEY TRANSPLANTATION CANDIDATES: A NEED FOR CONSENSUS.

Objective: To assess the evolving standards of care for hyperparathyroidism in kidney transplant candidates. Methods: An 11-question, Institutional Review Board-approved survey was designed and reviewed by multiple institutions. The questionnaire was made available to the American Society of Transplantation's Kidney Pancreas Community of Practice membership via their online hub from April through July 2019. Results: Twenty percent (n = 41) of kidney transplant centers responded out of 202 programs in the United States. Forty-one percent (n = 17) of respondents believed medical literature supports the concept that a serum parathyroid hormone level greater than 800 pg/mL could endanger the survival of a transplanted kidney and therefore makes transplantation in an affected patient relatively or absolutely contraindicated. Sixty-six percent (n = 27) said they occasionally recommend parathyroidectomy for secondary hyperparathyroidism prior to transplantation, and 66% (n = 27) recommend parathyroidectomy after transplantation based on persistent, unsatisfactory posttransplantation parathyroid hormone levels. Forty-six percent (n = 19) prefer subtotal parathyroidectomy as their choice; 44% (n = 18) had no standard preference. Endocrine surgery and otolaryngology were the most common surgical specialties consulted to perform parathyroidectomy in kidney transplant candidates. The majority of respondents (71%, n = 29) do not involve endocrinologists in the management of kidney transplantation candidates. Conclusion: Our survey shows wide divergence of clinical practice in the area of surgical management of kidney transplantation candidates with hyperparathyroidism. We suggest that medical/surgical societies involved in the transplantation care spectrum convene a multidisciplinary group of experts to create a new section in the kidney transplantation guidelines addressing the collaborative management of parathyroid disease in transplantation candidates. Abbreviations: AACE = American Association of Clinical Endocrinologists; AAES = American Association of Endocrine Surgeons; AHNS = American Head and Neck Society; CKD = chronic kidney disease; CKD-MBD = chronic kidney disease-mineral and bone disorder; ESRD = end-stage renal disease; HPT = hyperparathyroidism; KDIGO = Kidney Disease Improving Global Outcomes; KT = kidney transplantation; KTC = kidney transplant candidate; PTH = parathyroid hormone; PTX = parathyroidectomy; US = ultrasonography.