Surgical Urgency, Patient Comorbidities, and Socioeconomic Factors in Surgical Site Infections in Pediatric Surgery.

BACKGROUND: The rise of value-based purchasing has led to decreased compensation for hospital-acquired conditions, including surgical site infections (SSI). This study aims to assess the risk factors for SSI in children and teenagers undergoing gastrointestinal surgery across US hospitals. METHODS: The 2018-2020 Nationwide Readmissions Database was queried for patients undergoing gastrointestinal surgery under the age of 18. The primary outcome was SSI during index admission or readmission within a year. Comparison groups were elective, trauma, and emergent surgery based on anatomic location and urgency. Univariable comparison used chi-squared tests for relevant variables. Confounders were addressed through multivariable logistic regression with significant variables from univariable analysis. RESULTS: 113 108 total patients met the study criteria. The SSI rate during admission or readmission was 2.9% (n = 3254). Infections during admission and readmission were 1.4% (n = 1560) and 1.5% (n = 1694), respectively. The most common site was organ space (48.6%, n = 1657). Increased infection risk was associated with trauma (OR 1.80 [1.51-2.16] P < .001), emergency surgery (OR 1.31 [1.17-1.47] P < .001), large bowel surgery (OR 2.78 [2.26-3.43] P < .001), and those with three or more comorbidities (OR 2.03 [1.69-2.45] P < .001). Investor-owned hospitals (OR .65 [.56-.76] P < .001) and highest quartile income (OR .80 [.73-.88] P < .001) were associated with decreased infection risk. CONCLUSIONS: Pediatric patients undergoing gastrointestinal surgery face an elevated risk of SSI, especially in trauma and emergency surgeries, particularly with multiple comorbidities. Meanwhile, a reduced risk is observed in high-income and investor-owned hospital settings. Hospitals and surgeons caring for high risk patients should advocate for risk adjustment in value-based payment systems.

Fulminant Overwhelming Necrotizing Vibrio vulnificus Sepsis Secondary to Oyster Consumption.

Vibrio vulnificus is an opportunistic gram-negative rod-shaped bacteria found in warm, low salinity waters. Transmission through open wounds or consumption of contaminated seafood can lead to wound infections, sepsis, and potentially death. A 44-year-old man with a history of poly-substance abuse, cirrhosis, and recent oyster consumption presented to the emergency department in June with acute onset bilateral leg pain associated with rash and fever. Within 6 hours of his arrival, the rash rapidly progressed to large bullae with extensive necrosis ascending to the level of the abdomen, and he developed septic shock. Despite prompt surgical intervention and appropriate antibiotic and resuscitative therapies, the patient had progressive multi-system organ failure and died 7 days after admission. Concurrent necrotizing fasciitis with sepsis secondary to V. vulnificus infection is rare and potentially fatal, as demonstrated in this case.

Comparing Severely Injured Trauma Patients Admitted to Investor-Owned versus Public and Not-For-Profit Hospitals Reveals Opportunities for Improvement in the US.

BACKGROUND: Non-elderly trauma patients represent the largest portion of preventable years of life loss in the US. The purpose of this study was to compare outcomes in patients admitted to investor-owned vs public and not-for-profit hospitals across the US. MATERIAL AND METHODS: The Nationwide Readmissions Database 2018 was queried for trauma patients with an Injury Severity Score greater than 15 and age 18-65 years. The primary outcome was mortality; secondary outcomes were prolonged length of stay (LOS) greater than 30 days, readmission within 30 days, and readmission to a different hospital. Patients admitted to investor-owned hospitals were compared to public and not-for-profit hospitals. Univariable analysis was performed using chi-squared tests. Multivariable logistic regression was performed for each outcome. RESULTS: 157 945 patients were included with 11.0% (n = 17 346) admitted to investor-owned hospitals. The overall mortality rate and prolonged LOS were similar for both groups. The overall readmission rate was 9.2% (n = 13 895), with the rate in investor-owned hospitals at 10.5% (n = 1,739, P < .001). Multivariable logistic regression revealed investor-owned hospitals had an increased risk of readmission (OR 1.2 [1.1-1.3] P < .001) and readmission to a different hospital (OR 1.3 [1.2-1.5] P < .001). DISCUSSION: Severely injured trauma patients have similar rates of mortality and prolonged length of stay in investor-owned vs public and not-for-profit hospitals. However, patients admitted to investor-owned hospitals have an increased risk of readmission and readmission to different hospitals. Efforts to improve outcomes after trauma must consider hospital ownership and readmission to different hospitals.

Low Threshold for Laparoscopic Exploration in Dementia Patients With Unexplained Abdominal Pain and Risk Factors for Acute Mesenteric Ischemia.

Acute mesenteric ischemia (AMI) is associated with a high mortality and morbidity. There are limited studies on the presentation and management of elderly dementia patients with AMI. The following case of an 88-year-old female with dementia presenting with AMI highlights the challenges in the care of elderly dementia patients with AMI, the importance of identifying risk factors and hallmarks of acute mesenteric ischemia early in the clinical course, and suggests that aggressive workup with diagnostic laparoscopy is crucial to timely diagnosis and effective care.

Comparing Payments to Surgeons From Drug and Medical Device Corporations Reveals Inequalities Between Genders and Specialties.

INTRODUCTION: Maintaining trust in the patient-doctor relationship requires transparency in the details of the financial relationships between physicians and drug and medical device corporations. These details are publicly available through the Open Payments database, and patients are encouraged to ask surgeons to interpret their implications. The purpose of this study was to better equip surgeons in responding to these inquiries and to compare the distribution of these payments by gender and specialty. METHODS: The 2021 Open Payments dataset was searched for all payments to surgeons from the 14 different specialties recognized by the American College of Surgeons. The total payments per surgeon were compared by calculating the mean and median payments. The Gini index, a measure of income inequality, was also calculated for each specialty. RESULTS: There were 96 724 surgeons who received over $755 million in payments from drug and medical device companies. There were 72 245 (74.7%) men and 24 479 (25.3%) women. The total amount of payments to men was $712 million (94.2%) and for women it was $44 million (5.8%). The overall Gini index was .9508. The specialty with the highest Gini index was pediatric surgery (.9844) and the lowest was cardiothoracic surgery (.8656). DISCUSSION: Male surgeons received disproportionately higher payments from drug and device corporations than female surgeons. Surgeons should be aware of their own standing within the Open Payments database in order to respond appropriately to patient inquiries.

Tracheostomy dislodgement: Are obese patients at increased risk?

BACKGROUND: Obesity is a risk factor for tracheostomy-related complications. We aimed to investigate whether obesity was associated with a risk of unplanned tracheostomy dislodgement or decannulation (DD). METHODS: Retrospective review of patients undergoing tracheostomy at a single institution from 2013 to 2019 was performed. The primary outcome was unplanned DD within 42 days. Obesity was assessed by body mass index (BMI) and skin-to-trachea distance (STT) measured on computed tomographic images. RESULTS: 25 (12%) episodes of unplanned DD occurred in 213 patients within 42 days. BMI ≥35 kg/m2 was associated with STT ≥80 mm (p < 0.0001). On multivariate analysis, STT ≥80 mm but not BMI was an independent predictor of unplanned DD (hazard ratio = 8.34 [95% confidence interval 2.85-24.4]). CONCLUSIONS: STT ≥80 mm was a better predictor of unplanned DD than BMI. Assessment of STT in addition to BMI may be useful to identify patients that would benefit from extended length tracheostomy tubes.

Pediatric ACL Revision Using Salvaged Iliotibial Band Autograft in a Physeal-Sparing Multiligamentous Knee Reconstruction: A Case Report.

CASE: Iliotibial band (ITB) autograft is used for anterior cruciate ligament (ACL) reconstruction in prepubescent patients. No reports have described ITB salvage techniques for failed reconstruction. We describe a 13-year-old boy who sustained a multiligamentous knee injury, experienced a failed primary reconstruction, and required a revision ITB ACL, lateral collateral ligament, and posterior lateral corner reconstruction with reuse of his ITB autograft. At the 2-year follow-up, he returned to playing competitive sports. CONCLUSION: This case shows that salvage of an ITB ACL autograft can be an option in early reconstruction failure.

Sequence of Pelvic Examination Does Not Affect Patients With Baseline Vulvovaginal Syndromes: A Randomized Clinical Trial.

OBJECTIVE: The purpose of this study is to determine the optimal sequence in performing a pelvic examination to reduce discomfort in patients with baseline vaginal pain. METHODS: A randomized controlled trial of women presenting for a new appointment at the Drexel Vaginitis Center was conducted. Women were assigned to either group A, a Q-tip touch test, speculum examination, then bimanual examination, or group B, a Q-tip touch test, bimanual examination, then speculum examination. The primary outcome was visual analog scales to assess pain at baseline and after each portion of the examination. Secondary outcomes were responses to questionnaires for self-esteem, quality of life, and sexual function. RESULTS: Two hundred women were enrolled in the trial. For both group A and group B, each portion of the examination was similarly scored regardless of whether the speculum examination was performed before or after bimanual examination. Pain during the speculum examination was higher than pain during the other components of the examination, although not significant (P = 0.65).When looking at reported pain outcomes, outcomes did not differ as a whole or between groups in relation to sexual activity, sexual orientation, and previous hysterectomy. The data were not significantly different between groups for self-esteem scores, sexual dysfunction, or quality of life scores. CONCLUSION: In women with baseline vaginal pain, there was no difference in pain scores between the different components of the pelvic examination, nor is there a significant difference in pain during the examination compared with their baseline pain. Most patients reported minimal pain during each component.