Analysis of Surgical Residents' Salaries and Associated Funding During Eight Residency Training Cycles: Toward Improving Future Residents' Benefits and Compensation.

INTRODUCTION: We aimed to investigate the trends in surgical residents' salaries across the nation and by region from 2014-2015 to 2021-2022 to identify areas for improvement in resident benefits and compensation. METHODS: This is a retrospective study investigating the trends in US medical resident salaries from 2014-2015 to 2021-2022. Residency salary was analyzed over time, by region, and between surgical specialties both unadjusted and adjusted for cost of living. Salary by surgical specialty was collected from available years 2014-2015 to 2019-2020. Trends in residency salaries were also compared to the trends in graduate medical education (GME) Medicare funding. RESULTS: The average resident salary/cost of living ratio did not significantly change over the study period (2014-2015: 0.96, 2020-2021, 0.96, P = 0.654). The South and Midwest had significantly higher average resident salaries than the Northeast (P < 0.001) and West (P < 0.001) after adjusting for the cost of living. The average total GME Medicare funding per resident increased significantly more than the average resident salary ($12,278 versus $4540, P < 0.001). The average general surgery resident salary (2014-2015: $57,000, 2019-2020: $61,500, Δ = $4500) increased significantly less than the average salary of all specialties (2014-2015: $51,586, 2019-2020: $57,191, Δ = $5605, P = 0.001). CONCLUSIONS: Residency salaries have increased marginally from 2014-2015 to 2021-2022 and remain below the average US cost of living. Residency salaries vary significantly between surgical specialties and by region. Discussions aimed at reformulating GME compensation that takes into consideration regional differences in cost of living are needed.

Analysis of Biomechanics of Motor Vehicle Collisions for Passenger Cars: Implications for Passenger Vehicle Safety and Future Car Design Innovations.

INTRODUCTION: Investigating biomechanics of injury patterns from motor vehicle collisions (MVCs) informs improvements in vehicle safety. This study aims to investigate two-vehicle MVCs involving a passenger car and specific injury patterns associated with sources of injury, collision biomechanics, vehicle properties, and patient outcomes. METHODS: Retrospective cohort study conducted to evaluate the biomechanics of specific injury patterns seen in MVCs involving passenger cars using the Crash Injury Research Engineering Network database between the years 2005 and 2015. RESULTS: A total of 631 MVC cases were included from 2005 to 2015. The majority of cases involved injuries to the head or neck, the thorax, and the abdomen (80.5%). Head/neck injuries from the steering wheel were associated with significantly higher injury severity score compared to those from seatbelts (26.11 versus 18.28, P < 0.001) and airbags (26.11 versus 20.10, P = 0.006), as well as a >6-fold higher fatality rate (P = 0.019). Thoracic injuries caused by the center console were twice as likely to be fatal than those caused by the seatbelt (P = 0.09). CONCLUSIONS: Occupants suffering injuries to the head/neck, the thorax, and the abdomen had higher injury severity score and fatality rates compared to other body regions, demonstrating that manufacturing and safety guidelines should focus on minimizing these injury patterns. Head/neck injuries caused by the steering wheel were associated with worse outcomes compared to those caused by seatbelts and airbags, further emphasizing the benefits of these critical safety features. Integration of innovative safety features like center-mounted airbags may improve occupant safety.

The Role of Pericardial Window Techniques in the Management of Penetrating Cardiac Injuries in the Hemodynamically Stable Patient: Where Does It Fit in the Current Trauma Algorithm?

INTRODUCTION: Penetrating cardiac injuries (PCIs) have high in-hospital mortality rates. Guidelines regarding the use of pericardial window (PW) for diagnosis and treatment of suspected PCIs are not universally established. The objective of this review was to provide a critical appraisal of the current literature to determine the effectiveness and safety of PW as both a diagnostic and therapeutic technique for suspected PCIs in patients with hemodynamic stability. METHODS: A review was conducted using PubMed/MEDLINE, Google Scholar, and Embase to identify literature evaluating the accuracy and therapeutic efficacy of PW and its role in a hemodynamically stable patient with penetrating thoracic or thoracoabdominal trauma. RESULTS: Eleven studies evaluating diagnostic PW and two studies evaluating therapeutic PW were included. These studies ranged from (y) 1977 to 2018. Existing literature indicates that PW is highly sensitive (92%-100%) and specific (96%-100%) for the diagnosis of suspected PCIs. PW and drainage, when compared with sternotomy, may be associated with decreased total hospital stay (4.1 versus 6.5 d; P < 0.001) and intensive care unit stay (0.25 versus 2.04 d; P < 0.001) along with similar mortality and complication rates after the management of hemopericardium. CONCLUSIONS: In a hemodynamically stable patient presenting with penetrating cardiac trauma with a high suspicion for PCI, PWs can (1) facilitate prompt diagnosis in the event of equivocal ultrasonography findings and (2) serve as an effective therapeutic modality with the benefit of potentially avoiding more invasive procedures. Subxiphoid, transdiaphragmatic, and laparoscopic approaches for PW have been shown to have similar efficacy and safety.

Preoperative and Postoperative Cognitive Assessment in Geriatric Patients Following Acute Traumatic Injuries: Towards Improving Geriatric Trauma Outcomes.

INTRODUCTION: A growing percentage of the US population is over the age of 65, and geriatrics account for a large portion of trauma admissions, expected to reach nearly 40% by 2050. Cognitive status is important for operative management, especially in elderly populations. This study aims to investigate preoperative and postoperative cognitive function assessment tools in geriatric patients following acute trauma and associated outcomes, including functional status, postdischarge disposition, mortality, and hospital length of stay (H-LOS). METHODS: A literature search was conducted using Medline/PubMed, Google Scholar, Embase, JAMA Networks, and Cochrane databases for studies investigating the use of cognitive assessment tools for geriatric patients with acute trauma. The last literature search was conducted on November 13, 2021. RESULTS: Ten studies were included in this review, of which five focused on preoperative cognitive assessment and five focused on postoperative. The evidence suggests patients with preoperative cognitive impairment had worse functional status, mortality, and postdischarge disposition along with increased LOS. Acute trauma patients with postoperative cognitive impairment also had worse functional status, mortality, and adverse postdischarge disposition. CONCLUSIONS: Preoperative and postoperative cognitive impairment is common in geriatric patients with acute trauma and is associated with worse outcomes, including decreased functional status, increased LOS, and adverse discharge disposition. Cognitive assessment tools such as MMSE, MoCA, and CAM are fast and effective at detecting cognitive impairment in the acute trauma setting and allow clinicians to address preoperative or postoperative cognitive impairments to improve patient outcomes.

Gender Distribution of First and Senior Authorship Across Most Cited Studies Within the Top Ten Surgical Journals From 2015-2020: Cementing Women Academic Surgery Representation.

INTRODUCTION: The aim of this study is to investigate the gender distribution of first and senior authors in the most highly cited original research studies published in the top 10 surgical journals from 2015 to 2020 to identify disparities and changes over time. METHODS: A retrospective study analyzing the gender distribution of first and senior authors in the top 10 most cited studies from the top 10 surgical journals from 2015 to 2020. The genders of the first and senior authors of each study were assessed using National Provider Identifier (NPI) numbers or pronouns from institutional biographies or news articles. RESULTS: The genders of 1200 first and senior authors from 600 original research studies were assessed. First author gender distribution consisted of 71.8% men, 22.3% women, 0% non-binary, and 5.8% unknown. Senior author gender distribution was 82.3% men, 14.3% women, 0% non-binary, and 3.3% unknown. Studies published by first authors who are women received more citations than those published by first authors that are men in 2015 (169.1 versus 112.9, P = 0.002) and 2016 (144.2 versus 101.5, P = 0.011). There was an increase in first authorship among men from 2015 to 2020 (P = 0.035). CONCLUSIONS: Men represent a significantly higher proportion of both first and senior authorships in top surgical research and the gap has widened from 2015 to 2020. However, studies written by women first authors received significantly more citations than those written by men.

The Association Between Early Versus Late Physical Therapy Initiation and Outcomes of Trauma Patients With and Without Traumatic Brain Injuries.

BACKGROUND: There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients. METHODS: A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05. RESULTS: A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05). CONCLUSIONS: Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.

A Closer Look at the Rising Epidemic of Mass Shootings in the United States and Its Association With Gun Legislation, Laws, and Sales.

INTRODUCTION: Mass shootings pose a considerable threat to public safety and significantly cost the United States in terms of lives and expenses. The following are the specific aims of this study: (1) to assess US mass shootings, firearm-related sales, laws, and regional differences from 2015 to 2021 and (2) to investigate changes in mass shootings and firearm sales before and during the Coronavirus Disease 2019 pandemic. METHODS: A retrospective review was conducted of mass shootings, gun sales, and laws regarding the minimum age required to purchase a firearm within the United States from 2015 to 2021. The 10 states/regions with the greatest mean mass shootings/capita from 2015 to 2021 were selected for further analysis. RESULTS: Mass shootings correlated significantly with firearm sales from 2015 to 2021 nationwide (P < 0.02 for all). The growth in mass shootings, the number killed/injured, and gun sales were greater in 2020 and 2021 compared to the years prior. The 10 states with the highest mean mass shooting/capita over the study period were Alabama, Arkansas, the District of Columbia, Illinois, Louisiana, Maryland, Mississippi, Missouri, South Carolina, and Tennessee. No significant correlation was found between the number of mass shootings/capita and the minimum age to purchase a firearm. CONCLUSIONS: Firearm sales correlated significantly with mass shootings from 2015 to 2021. Mass shootings and gun sales increased at greater rates during the Coronavirus Disease 2019 pandemic compared to the years before the pandemic. Mass shootings exhibited inconsistent trends with state gun laws regarding the minimum age to purchase a firearm. Future studies may consider investigating the methods by which firearms used in mass shootings are obtained to further identify targets for prevention.

Shifting the Surgical Residency Match to a 100% Virtual Interview Format During the COVID-19 Pandemic, How has It Affected Placement Into Surgical Training Programs?

INTRODUCTION: The AAMC transitioned to virtual interview formats for the 2020-2021 residency match. This study aims to examine the impact of the 100% virtual interview format for the 2020-2021 residency match on both application and match changes for multiple surgical specialties, including neurosurgery (NS), orthopedic surgery (OS), plastic surgery (PS), general surgery (GS), thoracic surgery (TS), and vascular surgery (VS). METHODS: Cross-sectional study comparing application and match changes between the in-person 2019-2020 and virtual 2020-2021 residency match cycles for different surgical specialties. RESULTS: There was an overall increase in the number of applicants for 5 of the surgery specialties but not VS, and an overall increase in the number of applications per residency program across all specialties. The average number of applications per applicant also increased, except in TS. There were no major match changes except in TS, which saw an increase in number of spots filled by MDs to nearly 100% from 84.2% in the previous cycle. CONCLUSION: The switch to the 100% virtual 2020-2021 residency match interview format was associated with an overall increase in the number of applications per program and number of applications per applicant across multiple surgical specialties. There was a decrease in the number of applicants to VS and an increase in the number of applications per applicant. The switch to a virtual interview format in 2020-2021 was also associated with an increase in TS spots filled by MDs to almost 98%, increasing the already concerning TS match disparity for DO and IMG applicants.

Increasing lengths of rank order lists of applicants and programs of US medical residencies.

BACKGROUND: To match medical students into residency training programs, both the program and student create rank order lists (ROLs). We aim to investigate temporal trends in ROL lengths across 7 match cycles between 2014 and 2021 for both matched and unmatched residency applicants and programs. METHODS: retrospective study of ROLs of 7 match cycles, 2014-2021. Residency match and ROL data were extracted from the NRMP database to assess the number of programs filled and unfilled, length of ROLs, position matched, and average ranks per position for osteopathic (DO) and allopathic (MD) medical programs. RESULTS: For filled residency programs, the average ROL length consistently increased from 70.72 in 2015 to 88.73 in 2021 (P = .003), with ROL lengths consistently longer for filled vs unfilled residency programs (P < .001). The average ROL length for matched applicants increased consistently from 10.41 in 2015 to 12.35 in 2021 (P = .002), with matched applicants having consistently longer ROLs than unmatched applicants (P < .001). From 2015 to 2021, in both MD and DO applicants, progressively lower proportions of applicants matched their first and second choices. CONCLUSION: Trends across the past 7 residency match cycles suggest that ROL lengths for both programs and applicants have been increasing with matched programs and applicants submitting significantly longer ROLs than unmatched applicants. Additionally, fewer applicants are matching at their preferred programs over time. Our findings support the mounting evidence that the Match has become increasingly congested and we discuss the possible factors that may be contributing to the current state of the Match as well as potential solutions.

Indications and Recommendations for Tracheostomy in Trauma Population With COVID-19 Infection: A Review of the Literature.

This review explores the current body of evidence pertaining to tracheostomy placement in COVID-19 seropositive patients and summarizes the research by tracheostomy indications, timing, and procedure. Literature review was performed in accordance with the 2020 PRISMA guidelines and includes 12 papers discussing protocols for adult patients seropositive for COVID-19. The studies demonstrated high mortality rates after tracheostomy, especially in geriatric patients, and suggested a multifactorial determination of whether to perform a tracheostomy. There was inconclusive data regarding wait time between testing seropositive, tracheostomy, and weaning off of ventilation. COVID-19 generally reaches highest infectivity between days 9 and 10; furthermore, high early mortality rates seen in COVID-19 may confound mortality implicated by tracheostomy placement. Due to the aerosol-generating nature of tracheostomy placement, management and maintenance, techniques, equipment, and personnel should be carefully considered and altered for COVID-19 patients. With surgical tracheostomy, literature suggested decreased usage of electrocautery; with percutaneous tracheostomy, single-use bronchoscope should be used. The nonemergent exchange of tracheostomy should be done only after the patient tested negative for COVID-19. Placement of tracheostomy should only be considered in COVID-19 patients who are no longer transmissible, with rigorous attention to safety precautions. Understanding procedures for airway maintenance in a respiratory disease like COVID-19 is imperative, especially due to current shortages in ventilators and PPE. However, because of a lack of available data and its likelihood of change as more data emerges, we lack complete guidelines for tracheostomy placement in COVID-19 seropositive patients, and those existing will likely evolve with the disease.

Operative Confidence Among U.S General Surgery Residents.

BACKGROUND: General surgery residents (GSRs) must develop operative autonomy skills to practice independently after graduation. We aim to investigate perceived confidence and operative autonomy of GSR physicians in order to identify and address influential factors. METHODS: A 28-question anonymous online survey was distributed to 23 United States general surgery residency programs. Multivariable logistic regression was used for calculating the adjusted odds ratio (aOR) for binary outcomes. Significance was defined as P-values ≤ .05 or 95% confidence intervals (CIs) >1 or <1. RESULTS: There were 120/558 (21.5%) GSR respondents. General surgery residents with >200 overall operative case volume reported significantly higher confidence with minor cases (P = .05) and major cases (P = .02). General surgery residents that performed both minor and major surgeries reported higher confidence with minor cases at 85.7% compared to GSRs that performed mostly minor surgeries (64.7%) and mostly major surgeries (62.5%). General surgery residents who performed >50 minor surgeries during their PGY 1 and 2 were less confident with major cases than GSRs who performed <50 minor surgeries (aOR: 19.98, 95% CI: 1.26, 318). General surgery residents from community teaching hospitals reported higher confidence with major and minor cases than GSRs from university teaching hospitals and combined programs. CONCLUSION: Increased case volume, predominant case type, early surgical experience during PGY 1 and 2 years, and training at community teaching hospitals were identified as the most important factors that positively influence perception of operative confidence and autonomy among GSRs. These may have important implications in the development of future surgeons.

Trends of Cancer Screenings, Diagnoses, and Mortalities During the COVID-19 Pandemic: Implications and Future Recommendations.

INTRODUCTION: The impact of the COVID-19 pandemic on cancer screenings and care has yet to be determined. This study aims to investigate the screening, diagnosis, and mortality rates of the top five leading causes of cancer mortality in the United States from 2019 to 2021 to determine the potential impact of the COVID-19 pandemic on cancer care. METHODS: A retrospective cohort study investigating the impact of the COVID-19 pandemic on screening, diagnoses, and mortality rates of the top five leading causes of cancer death (lung/bronchus, colon/rectum, pancreas, breast, and prostate), as determined by the National Institute of Health (NIH) utilizing The United States Healthcare Cost Institute and American Cancer Society databases from 2019 to 2021. RESULTS: Screenings decreased by 24.98% for colorectal cancer and 16.01% for breast cancer from 2019 to 2020. Compared to 2019, there was a .29% increase in lung/bronchus, 19.72% increase in colorectal, 1.46% increase in pancreatic, 2.89% increase in breast, and 144.50% increase in prostate cancer diagnoses in 2020 (all P < .01). There was an increase in the total number of deaths from colorectal, pancreatic, breast, and prostate cancers from 2019 to 2021. CONCLUSION: There was a decrease in the screening rates for breast and colorectal cancer, along with an increase in the estimated incidence and mortality rate among the five leading causes of cancer deaths from 2019 to 2021. The findings suggest that the COVID-19 pandemic is associated with impaired cancer screening, diagnosis, and care, and further emphasizes the need for proactive screening and follow-up to prevent subsequent cancer morbidity and mortality.

Nationwide Analysis of Biomechanics of Motor Vehicle Collisions Involving Passenger Vehicle and Associated Outcomes: Towards Improving Vehicle Safety Standards and Regulations.

BACKGROUND: Motor vehicle collisions (MVCs) pose significant mortality and economic burden on the United States. Biomechanics research may guide future vehicle innovation. The objective of this study is to investigate the biomechanics of two-vehicle MVCs involving passenger vehicle (PV) to evaluate associated injury patterns and outcomes including mortality. METHODS: A retrospective cohort study of cases from the Crash Injury Research Engineering Network database was performed to evaluate the biomechanics (angle of impact, seatbelt use, and airbag deployment) of two-vehicle MVCs involving at least one PV from 2005-2015. RESULTS: Out of 629 MVCs evaluated, lateral collisions were most common (49.5%), followed by head-on (41.3%) and rear-end (9.2%) collisions. Thoracic injuries accounted for 30.1%, 31.4%, and 31.1% of injuries in lateral, head-on, and rear-end collisions, respectively, and were the most common body region injured for all collision types. Seatbelt use was associated with shorter ICU stay (10.9 vs 19.1 days, P = .036) and mortality (Cramer's V = .224, P < .001), but a greater average number of injuries (10.2 injuries vs 8.6 injuries, P = .011). CONCLUSION: Passenger vehicle are commonly involved in MVCs nationwide and efforts are needed to prevent occupant injuries and fatalities. The incorporation of energy-absorbing material into common points of contact within the vehicle interior may decrease the severity of these injuries. Seatbelt use remains a protective factor against MVC-fatalities but is associated with collateral injuries and should be a focus of further innovation.

Nationwide Analysis of Motorcycle-Associated Injuries and Fatalities in the United States: Insufficient Prevention Policies or Abandoned Laws?

BACKGROUND: Motorcycle road traffic collisions are a major cause of mortality in the United States. We aimed to analyze the temporal and statewide trends in motorcycle collision fatalities (MCFs) nationwide and their association with state laws regarding motorcycle helmet requirements, lane splitting, speeding, intoxicating driving, and red light cameras. METHODS: A retrospective review of United States MCF/capita from 2015 to 2019 was performed using the Fatality Analysis Reporting System database. MCF/capita was defined as a motorcyclist death per 100 000 motorcyclist registrations. Independent-samples t-test and ANOVA were used to determine differences, with significance defined as P < .05. Linear regression analysis and Pearson's correlation were used to further determine associations between variables. RESULTS: The majority of fatalities occurred in males (n = 21 354, 91.0%), ages 25-54 (n = 13 728, 58.5%), and Caucasians (n = 19 195, 81.8%). A total of 24 states and DC exhibited positive trends in MCF/capita from 2015 to 2019. There was no significant difference in MCF/capita between states who had mandatory helmet laws for all, partial requirements, and states with no law (63.4 vs 54.3 vs 33.6, P = .360). Among fatalities involving alcohol, a significantly greater number of MCF/capita were found above the legal limit of .08 compared to the group with a blood alcohol concentration of .01-.07 (17.8 vs 4.5, P < .001). CONCLUSION: Motorcyclist fatalities continue to pose a public health risk, with 24 states showing an upward trend. Additional interventions and laws are needed to decrease the number of motorcyclist deaths. Further strategy on implementation and enforcement of helmet laws and alcohol consumption may be an essential component.

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review.

BACKGROUND: We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting. METHODS: PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively. RESULTS: A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient's prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear. CONCLUSION: The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.

Gender Distribution & Rank of Authorship in Surgical Literature.

BACKGROUND: Authorship of surgical literature is important for the career advancement of surgeons, and gender disparities in authorship may hinder the representation and leadership of women within academic surgery. The aim of this systematic review and meta-analysis was to evaluate the gender distribution of first, senior, and overall authorship in peer-reviewed surgical journal studies across all surgical specialties to determine if disparities exist. METHODS: PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the gender distribution of authorship of surgical literature published before December 10th, 2021. Meta-analysis was performed and Cohen's Q test for heterogenous effects was used to determine whether random or fixed-effects models were appropriate. RESULTS: Fifteen studies investigating gender distribution of authorship met inclusion, which included a total of 136,627 pooled studies. The meta-analysis demonstrated the meta-proportion of first authorship for women to be 20.6% (95% CI: 13.9, 28.2), the meta-proportion of senior authorship for women to be 11.9% (95% CI: 6.6, 18.5), and the meta-proportion of overall authorship for women to be 23% (95% CI: 16.2, 30.7). In addition, the proportion of senior authorship for women was found to be significantly lower than the proportion of overall authorship for women (11.9% versus 23.0%, P = .0106). CONCLUSION: There is a significantly smaller proportion of women who are first, senior, and overall authors in surgical literature compared to their colleagues who are men. Sustainable and effective solutions aimed at improving the representation of women surgeons in surgical research and research leadership are necessary.

Global Longitudinal Strain as an Efficient Prognostic Tool in Hypertrophic Cardiomyopathy With Preserved Left Ventricular Ejection Fraction.

Intending to demonstrate the utility of the global longitudinal strain (GLS) in patients with hypertrophic cardiomyopathy (HCM) and preserved ejection fraction, we describe a case of a 54-year-old female who presented to our emergency department with an acute onset of palpitations and chest pain. The patient was noted to have a new onset of atrial fibrillation. An echocardiogram showed an unimpaired ejection fraction suggesting normal left ventricular systolic function with findings of concentric left ventricular and apical hypertrophy. However, the speckled ultrasound revealed a GLS of -6.2%, suggesting marked impairment of ventricular wall movement. A CHA2DS2-VASc score was calculated and yielded a score of 2, indicating a moderate risk for thromboembolism. After a full evaluation of the case, the patient was started on anticoagulation due to her GLS result that suggested stasis within the left ventricle that may lead to a thrombus. Additional advice was to follow up closely for possible automatic implantable cardioverter defibrillator placement. We conclude that GLS is a cheap and easy tool to utilize as an additional prognostic marker for cardiovascular complications, particularly among those who have progression of HCM or start with symptoms such as atrial fibrillation and may have impaired left ventricular systolic function despite a preserved ejection fraction. Thus, we encourage the medical community to utilize and further study this novel technology.

Mass Shootings and Their Proximity to a Public or Private School: Protecting the Health and Livelihood of Our Children.

INTRODUCTION: Firearm-related violence occupies the third leading age-adjusted mortality rate among all mechanisms of injury. We aim to analyze the distribution of mass shootings in relation to the distance to the nearest public/private school in the United States. METHODS: A retrospective study investigating mass shootings and proximity to school areas. Information regarding mass shootings was obtained from the Gun Violence Archive. The locations of public/private schools for the 2019-2020 school year were obtained from the National Center for Education Statistics and the Euclidian distance from a mass shooting to the nearest school was measured. RESULTS: There were 417 mass shootings in 2019 and 610 in 2020. The average distance from a mass shooting to the nearest public/private school was 0.52 miles in 2019 and 0.57 miles in 2020. Most mass shootings occurred within 0.30 miles of a school in 2019 and 0.40 miles in 2020. There was no significant association between average distance of a mass shooting to a public/private school and the population density in 2019 (P = .313) or 2020 (P = .351). CONCLUSION: The growing number of mass shootings from 2019-2020 was associated with an average distance of <0.60 miles from the location of a mass shooting to a public or private school, highlighting the danger posed to children living and learning in these areas. Mass shootings are prevalent throughout the country and the close proximity of these events to places of learning warrants further investigation into policies and preventive measures aimed at preventing gun violence occurring near schools.

The Affordable Care Act and its Effects on Trauma Care Access, Short- and Long-term Outcomes and Financial Impact: A Review Article.

Objective: The purpose of this study is to evaluate the current evidence regarding the impact of the ACA on trauma outcomes and the financial impact on trauma patients and trauma systems. Background: Traumatic injuries are the leading cause of death and disability between the ages of 1 to 47 years. Uninsured status has been associated with worse outcomes and higher financial strain. The Affordable Care Act (ACA) was signed into law with the aim of increasing health insurance coverage. Despite improvements in insured status, it is unclear how the ACA has affected trauma. Methods: We conducted a literature search using PubMed and Google Scholar for peer-reviewed studies investigating the impact of the ACA on trauma published between January 2017 and April 2021. Results: Our search identified 20 studies that evaluated the impact of ACA implementation on trauma. The evidence suggests ACA implementation has been associated with increased postacute care access but not significant changes in trauma mortality. ACA implementation has been associated with a decreased likelihood of catastrophic health expenditures for trauma patients. ACA was also associated with an increase in overall reimbursement and amount billed for trauma visits, but a decrease in Medicaid reimbursement. Conclusions: Some improvements on the financial impact of ACA implementation on trauma patients and trauma systems have been shown, but studies are limited by methods of calculating costs and by inconsistent pre-/post-ACA timeframes. Further studies on cost-effectiveness and cost-benefit analysis will need to be conducted to definitively determine the impact of ACA on trauma.