Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database.

INTRODUCTION: Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT. METHODS: We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure. RESULTS: There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001). CONCLUSIONS: There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.

Feasibility of providing web-based education to patients prior to kidney transplant evaluation.

BACKGROUND: We previously developed web-based education to be used by patients prior to kidney transplant (KTX) evaluation. The current feasibility study evaluated patients' intervention uptake and barriers, and staff experiences of the clinic-wide implementation in preparation for a definitive comparative effectiveness trial. METHODS: Web links and login instructions to view 17 educational videos designed to promote KTX access were delivered via email or text to adults referred to a single transplant center between 10/2020 and 3/2021. Patient barriers were recorded. Non-completers were allowed to view the resources in the clinic. N = 7 clinic staff were interviewed about their experiences of in-clinic delivery of the web-education. Interviews were recorded with field notes and coded using simple content analysis. Patient characteristics and 30-month KTX access were examined with Chi-square, t-tests, and log-rank tests. RESULTS: Of 210 patients, 71% completed the self-education remotely (completers), 16% attempted but did not complete remotely (attempters), and 13% declined the web link invitation (decliners). Implementation barriers included technology access and use difficulties, unstable internet connectivity, limited staff time in clinic to facilitate technology use by patients, and limited technology attentiveness by patients in clinic. In 3-group comparisons, remote decliners were older with worse estimated posttransplant survival scores, and attempters were younger, more often Medicaid insured, and lived in higher area deprivation; both were more often deemed ineligible for KTX than completers. Between-group time-to-transplantation was non-significant (p = .571). CONCLUSION: The majority of patients accessed the web-education remotely; however, more vulnerable demographic populations reported greater problems accessing web-education. In-clinic delivery was burdensome to staff and patients. Future adaptive implementation strategies are needed to allow for adequate patient education.

The impact of disclosure of conflicts of interest in studies comparing robot-assisted and laparoscopic cholecystectomies-a persistent problem.

INTRODUCTION: Accurate disclosure of conflicts of interest (COI) is critical to interpretation of study results, especially when industry interests are involved. We reviewed published manuscripts comparing robot-assisted cholecystectomy (RAC) and laparoscopic cholecystectomy (LC) to evaluate the relationship between COI disclosures and conclusions drawn on the procedure benefits and safety profile. METHODS: Searching Pubmed and Embase using key words "cholecystectomy", laparoscopic" and "robotic"/"robot-assisted" retrieved 345 publications. Manuscripts that compared benefits and safety of RAC over LC, had at least one US author and were published between 2014 and 2020 enabling verification of disclosures with reported industry payments in CMS's Open Payments database (OPD) (up to 1 calendar year prior to publication) were included in the analysis (n = 37). RESULTS: Overall, 26 (70%) manuscripts concluded that RAC was equivalent or better than LC (RAC +) and 11 (30%) concluded that RAC was inferior to LC (RAC-). Six manuscripts (5 RAC + and 1 RAC-) did not have clearly stated COI disclosures. Among those that had disclosure statements, authors' disclosures matched OPD records among 17 (81%) of RAC + and 9 (90%) RAC- papers. All 11 RAC- and 17 RAC + (65%) manuscripts were based on retrospective cohort studies. The remaining RAC + papers were based on case studies/series (n = 4), literature review (n = 4) and clinical trial (n = 1). A higher proportion of RAC + (85% vs 45% RAC-) manuscripts used data from a single institution. Authors on RAC + papers received higher amounts of industry payments on average compared to RAC- papers. CONCLUSIONS: It is imperative for authors to understand and accurately disclose their COI while disseminating scientific output. Journals have the responsibility to use a publicly available resource like the OPD to verify authors' disclosures prior to publication to protect the process of scientific authorship which is the foundation of modern surgical care.

Effect of musculature on mortality, a retrospective cohort study.

BACKGROUND: While often life-saving, treatment for head and neck cancer (HNC) can be debilitating resulting in unplanned hospitalization. Hospitalizations in cancer patients may disrupt treatment and result in poor outcomes. Pre-treatment muscle quality and quantity ascertained through diagnostic imaging may help identify patients at high risk of poor outcomes early. The primary objective of this study was to determine if pre-treatment musculature was associated with all-cause mortality. METHODS: Patient demographic and clinical characteristics were abstracted from the cancer center electronic database (n = 403). Musculature was ascertained from pre-treatment CT scans. Propensity score matching was utilized to adjust for confounding bias when comparing patients with and without myosteatosis and with and without low muscle mass (LMM). Overall survival (OS) was evaluated using the Kaplan-Meier method and Cox multivariable analysis. RESULTS: A majority of patients were male (81.6%), white (89.6%), with stage IV (41.2%) oropharyngeal cancer (51.1%) treated with definitive radiation and chemotherapy (93.3%). Patients with myosteatosis and those with LMM were more likely to die compared to those with normal musculature (5-yr OS HR 1.55; 95% CI 1.03-2.34; HR 1.58; 95% CI 1.04-2.38). CONCLUSIONS: Musculature at the time of diagnosis was associated with overall mortality. Diagnostic imaging could be utilized to aid in assessing candidates for interventions targeted at maintaining and increasing muscle reserves.

Donor rhabdomyolysis, acute kidney injury, and kidney transplant outcomes.

BACKGROUND: Donor rhabdomyolysis may constrain kidney utilization due to anticipated unfavorable graft outcomes-especially in combination with acute kidney injury (AKI). There is a paucity of empiric data to inform organ acceptance decision-making. METHODS: A single-center retrospective cohort study of adult transplant recipients of deceased-donor kidneys with reported donor creatine phosphokinase (CPK) levels was conducted between 2014 and 2020. Recipients of CPK ≥ 1000 U/L kidneys were propensity matched to CPK < 1000 recipients according to outcome-predictive baseline covariates, except AKI. RESULTS: A total of 254 kidney transplants were propensity matched into CPK ≥ 1000 (n = 90) versus CPK < 1000 (n = 90) groups. Transplant outcomes with high versus low CPK kidneys were similar in terms of delayed graft function (P = 0.64), 1-year estimated glomerular filtration rate < 25th percentile (P = 0.69) and mean (P = 0.58), and time to all-cause graft failure (P = 0.58). There was no interaction between AKI and high CPK for these outcomes. Extreme CPK thresholds as high as > 8672 U/L were not associated with overall graft survival in the unmatched sample (P = 0.81). CONCLUSIONS: In a single center study, donor rhabdomyolysis was not associated with short-term kidney transplant graft outcomes, nor was there an additive effect of AKI. However, studies with greater CPK and AKI severity and longer follow-up are warranted.

An assessment of perioperative outcomes for open, laparoscopic, and robot-assisted pancreaticoduodenectomy in New York State.

BACKGROUND: Minimally invasive techniques for pancreaticoduodenectomy (PD) are increasing in practice, however, data remains limited regarding perioperative outcomes. Our study sought to compare patients undergoing open pancreaticoduodenectomy (OPD) with those undergoing laparoscopic (LPD) or robot-assisted pancreaticoduodenectomy (RPD). METHODS: Patients who underwent PD during 2016-2018 were identified from the New York State Planning and Research Cooperative System database. RESULTS: Of the 1954 patients identified, 1708 (87.4%) underwent OPD, 165 (8.4%) underwent LPD, and 81 (4.2%) underwent RPD. The majority of patients were White (63.8%), males (53.3%) with a mean age of 65.4 years. RPD patients had a lower median Charlson Comorbidity Index (2) than OPD (3) or LPD (3, p = 0.01) and had a lower 30-day rate of complications (35.8% vs. 48.3% vs. 43.6% respectively, p = 0.05). After propensity-score matching, however, there were no differences between the groups regarding overall complications, surgical site infections, anastomotic leaks, or mortality (p = NS for all). OPD demonstrated a longer length of stay (median 8 days) compared to LPD (7 days) or RPD (7 days, p < 0.01). CONCLUSIONS: Patients undergoing LPD and RPD have a shorter length of hospital stay compared to OPD and there was no difference in overall morbidity or mortality when matched to similar patients.

Cross-sectional analysis of myosteatosis and physical function in pretreatment head and neck cancer patients.

BACKGROUND: Head and neck cancer (HNC) and its treatment are associated with muscle weakness and considerable long-term comorbidity. The goal of this study was to determine whether skeletal muscle density (SMD) as quantified from pretreatment computed tomography (CT) scans will correlate with measures of function and strength prior to treatment in physical function in HNC patients. PATIENTS AND METHODS: A cross-sectional analysis was conducted on 90 HNC patients. SMD (myosteatosis vs. normal) was calculated from pretreatment CT scans using SliceOmatic software. Pretreatment physical function was assessed via handgrip strength (HGS), the timed up and go test (TUG), and the short physical performance battery (SPPB). Demographic, cancer, and social characteristics were also collected as confounders. Linear regression models assessed the association between myosteatosis and measures of physical function. RESULTS: The 90 patients were predominately White, male, former smokers with an average BMI of 28.7 ± 5.7 kg/m2. Among men, adjusted models indicate, as compared to those with normal muscle density, the total SPPB score of those with myosteatosis was 1.57 points lower (p = 0.0008), HGS was 0.85 kg lower (p = 0.73), and TUG took 1.34 s longer (p = 0.03). There were no differences in women. CONCLUSION: Myosteatosis is associated with physical function prior to treatment in HNC patients. Larger studies are needed to examine the importance of exercise programs prior to and during treatment to build lean mass and improve long-term prognosis in HNC.

Outcomes following robot-assisted versus laparoscopic sleeve gastrectomy: the New York State experience.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) represents more than half of all bariatric procedures in the USA, and robot-assisted sleeve gastrectomy (RSG) is becoming increasingly common. There is a paucity of evidence regarding postoperative surgical outcomes (> 30 days) in RSG patients, especially as these patients move between multiple hospital systems. METHODS: Using 2012-2018 New York State's inpatient and ambulatory data from the Statewide Planning and Research Cooperative System, bivariate and multivariate analyses were employed to examine patient long-term outcomes, postoperative complications, and charges following RSG versus LSG in unmatched and propensity score-matched (PSM) samples. RESULTS: Among the 72,157 minimally invasive sleeve gastrectomies identified, 2365 (2.6%) were RSGs. In the PSM sample (2365 RSG matched to 23,650 LSG), RSG cases were more likely to be converted to an open procedure (2.3% vs 0.2% LSG patients, p < 0.01) and had a longer mean length of stay (LOS; 2.1 vs. 1.8 days LSG, p < 0.01). Postoperative complications were not different between RSG and LSG patients, but the proportion of emergency room visits resulting in inpatient readmissions was higher among RSG patients (5.5% vs. 4.2% in LSG patients, p < .01). Among the super obese (body mass index ≥ 50) patients, conversions to open procedure and LOS were also significantly higher for RSG versus LSG cases. Average hospital charges for the index admission ($47,623 RSG vs $35,934 LSG) and cumulative changes for 1 year from the date of surgery ($57,484 RSG vs $43,769 LSG) were > 30% higher for RSG patients. CONCLUSIONS: RSG patients were more likely to have conversions to open procedures, longer postoperative stay, readmissions, and higher charges for both the index admission and beyond, compared to LSG patients. No clear advantages emerged for the utilization of the robotic platform for either average risk or extremely obese patients.

Is New York State good at managing hollow viscus injury?

BACKGROUND: There are an estimated 100,000 cases of abdominal injury (ABI) in the USA, annually resulting in over $12 billion in direct medical cost and $18 billion in lost productivity. This study assesses the timeliness, safety, and efficacy of the surgical management of abdominal injuries (ABIs), hollow viscus injuries (HVIs), and colonic injuries (CIs) for patients residing in New York State (NYS). METHODS: Using data from NYS's Statewide Planning and Research Cooperative System (SPARCS), we identified all trauma patients with ABI admitted between 2006 and 2015. We subdivided ABI into HVI and CI using diagnosis and procedure codes and examined processes of care and outcomes adjusting for patient characteristics, injury severity score, structural, and process indicators. RESULTS: We identified 31,043 hospitalized patients with ABI, 71% were incurred from blunt forces. Most patients with ABI (72%) were treated at a Level I/II trauma center (TC) and 7% patients were transferred to Level I/II TC. Failure to be treated at Level I/II TC was associated with 16% increased hazard of death. HVI was diagnosed in 23% of ABI patients (n = 7294); 18% experienced delayed hollow viscus repair (dHVR); dHVR was associated with a 76% increased hazard of death. CI was diagnosed in 9% of ABI patients (n = 2921) and 18% experienced dHVR. Seventy-five percent of CI were repaired primarily (n = 1354). Less than 37% of stomas were reversed by 4 years of index trauma. CONCLUSION: Most abdominal trauma in NYS was caused by motor vehicle accidents, falls, and assault. dHVR and not being treated at Level I/II TC were associated with worse outcomes. More research is needed to reduce under-triage and delays in the operative treatment of blunt abdominal trauma.

Hardest-to-place kidney transplant outcomes in the United States.

The outcomes of hardest-to-place kidney transplants-accepted last in the entire match run after being refused by previous centers-are unclear, potentially translating to risk aversion and unnecessary organ discard. We aimed to determine the outcomes of hardest-to-place kidney transplants and whether the organ acceptance position on the match run sufficiently captures the risk. This is a cohort study of the United Network for Organ Sharing data of all adult kidney-only transplant recipients from deceased donors between 2007 and 2018. Multiple regression models assessed delayed graft function, graft survival, and patient survival stratified by share type: local versus shared kidney acceptance position scaled by tertile. Among 127 028 kidney transplant recipients, 92 855 received local kidneys. The remaining received shared kidneys at sequence number 1-4 (n = 12 322), 5-164 (n = 10 485) and >164 (n = 11 366). Hardest-to-place kidneys, defined as the latest acceptance group in the match-run, were associated with delayed graft function (adjusted odds ratio 1.83, 95% confidence interval [CI] 1.74-1.92) and all-cause allograft failure (adjusted hazard ratio [aHR] 1.11, 95% CI 1.04-1.17). Results of this IRB-approved study were robust to the exclusion of operational allocation bypass and mandatory shares. The hardest-to-place kidneys accepted later in the match run were associated with higher graft failure and delayed graft function.

The Early (2009-2017) Experience With Robot-assisted Cholecystectomy in New York State.

OBJECTIVE: The aim of this study was to examine real-life patterns of care and patient outcomes associated with robot-assisted cholecystectomy (RAC) in New York State (NYS). BACKGROUND: Although robotic assistance may offer some technological advantages, RACs are associated with higher procedural costs and longer operating times compared to traditional laparoscopic cholecystectomies (LCs). Evidence on long-term patient outcomes after RAC from large population-based datasets remains limited and inconsistent. METHODS: Using NYS inpatient and ambulatory surgery data from the Statewide Planning and Research Cooperative System (2009-2017), we conducted bivariate and multivariate analyses to examine patterns of utilization, complications, and secondary procedures following cholecystectomies. RESULTS: Among 299,306 minimally invasive cholecystectomies performed in NYS between 2009 and 2017, one thousand one hundred eighteen (0.4%) were robot-assisted. Compared to those undergoing LC, RAC patients were older, travelled further for surgery, and were more likely to have public insurance and preoperative comorbidities. RAC versus LC patients were more significantly likely to have conversions to open procedure (4.9% vs 2.8%), bile duct injuries (1.3% vs 0.4%), and major reconstructive interventions (0.6% vs 0.1%), longer median length of stay (3 vs 1 day), readmissions (7.3% vs 4.4%), and higher 12-month post-index surgery hospital charges (P < 0.01 for all estimates). Other postoperative complications decreased over time for LC but remained unchanged for RAC patients. CONCLUSIONS: Patients receiving RAC in NYS experienced higher rates of complications compared to LC patients. Addressing patient-, surgeon-, and system-level factors associated with intra/postoperative complications and applying recently promulgated safe cholecystectomy strategies coupled with advanced imaging modalities like fluorescence cholangiography to RAC may improve patient outcomes.

Video education to facilitate patient outreach about living kidney donation: A proof of concept.

BACKGROUND: Increasing living-donor kidney transplantation (LDKT) requires education of transplant candidates and their social network. This pre-post study tested the feasibility and acceptability of KidneyTIME, an intervention which leverages LDKT video-based educational content designed for sharing. METHODS: Adult kidney candidates undergoing transplant evaluation/re-evaluation and their caregivers at a single transplant center viewed different sets of KidneyTIME videos prior to evaluation. Change in LDKT knowledge, self-efficacy, and concerns was assessed before and immediately after exposure and 3 weeks later. Also assessed were post-exposure program feedback, online use, and living donor (LD) inquiry. RESULTS: A total of 82 candidates and 79 caregivers participated. Viewers of KidneyTIME demonstrated increases in mean LDKT knowledge by +71% and communication self-efficacy by +48%, and reductions in concerns by -21%. The intervention was received positively, with over 95% of participants agreeing that the videos were understandable, credible, and engaging. By 3 weeks follow-up, 58% had viewed it again, 63% of family clusters had shared it, and 100% would recommend the program to a friend. Time to LD inquiry was similar to historic controls. CONCLUSION: KidneyTime improved facilitators of LDKT, was rated as highly acceptable, and was highly shared, but did not impact LD inquiry during the COVID-19 pandemic.

Teaching surgery novices and trainees advanced laparoscopic suturing: a trial and tribulations.

INTRODUCTION: The benefits of minimally invasive surgery are numerous; however, considerable variability exists in its application and there is a lack of standardized training for important advanced skills. Our goal was to determine whether participation in an advanced laparoscopic curriculum (ALC) results in improved laparoscopic suturing skills. METHODS AND PROCEDURES: Study design was a prospective, randomized controlled trial. Surgery novices and trainees underwent baseline FLS training and were pre-tested on bench models. Participants were stratified by pre-test score and randomized to undergo either further FLS training (control group) or ALC training (intervention group). All were post-tested on the same bench model. Tests for differences between post-test scores of cohorts were performed using least squared means. Multivariable regression identified predictors of post-test score, and Wilcoxon rank sum test assessed for differences in confidence improvement in laparoscopic suturing ability between groups. RESULTS: Between November 2018 and May 2019, 25 participants completed the study (16 females; 9 males). After adjustment for relevant variables, participants randomized to the ALC group had significantly higher post-test scores than those undergoing FLS training alone (mean score 90.50 versus 82.99, p = 0.001). The only demographic or other variables found to predict post-test score include level of training (p = 0.049) and reported years of video gaming (p = 0.034). There was no difference in confidence improvement between groups. CONCLUSIONS: Training using the ALC as opposed to basic laparoscopic skills training only is associated with superior advanced laparoscopic suturing performance without affecting improvement in reported confidence levels. Performance on advanced laparoscopic suturing tasks may be predicted by lifetime cumulative video gaming history and year of training but does not appear to be associated with other factors previously studied in relation to basic laparoscopic skills, such as surgical career aspiration or musical ability.

Inpatient rehabilitation service utilization and outcomes under US ACA Medicaid expansion.

BACKGROUND: To investigate the impact of the US Medicaid expansion on care utilization and health outcomes of patients treated in the inpatient rehabilitation facilities (IRF). METHODS: A retrospective observational study with a difference-in-difference design. The data was obtained from Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI). Sample included all Medicaid beneficiaries (aged 18-64 years) who received initial inpatient rehabilitation for stroke, hip fracture (acute conditions), or joint replacement (elective condition) (N = 14,917) before (2013) and after (2016) the expansion. The study estimated the differences in length of stay, functional improvement, and possibility of returning to community before and after ACA Medicaid expansion in the expansion regions relative to the non-expansion regions. The analysis was fully adjusted for patient demographics, health conditions, facility characteristics and time trends. RESULTS: Compared with non-expansion states, service volume in the expansion regions increased more for the two acute conditions (49 and 27% vs. 1% and - 4%) and decreased less for the selective condition (- 12% vs. -34%) after ACA Medicaid expansion. Medicaid expansion was associated with significant decreases in patient functional improvements (- 1.63 points for stroke, - 3.61 points for fracture and - 2.73 points for joint; P < 0.05). Length of stay and the possibility of returning to community after discharge were not significantly different. CONCLUSIONS: Medicaid expansion was associated with increases in the utilization of inpatient rehabilitation services and decreases in the patient functional improvements. Cautions should be taken with the decreases in functional improvements among some subpopulation in the short-term; longer follow up periods are needed to account for gradual changes in patient needs.

Transplant Outcomes of Donation After Circulatory Death Livers Recovered With Versus Without Premortem Heparin Administration.

Premortem heparin administration during donation after circulatory death (DCD) organ recovery is thought to optimize liver perfusion. However, premortem heparinization is not universally practiced in the United States and limited data exist regarding its utility. US registry data were accessed between January 1, 2003, and March 10, 2017, and 2 cohorts were ascertained: (1) DCD donor livers recovered for transplantation (n = 5495) and (2) liver-only adult transplant recipients of DCD livers (n = 3754). Exclusions were donor unknown heparin status (n = 40), positive donor hepatitis B surface antigen (n = 4) and hepatitis C virus (n = 120) serologies, and for the outcomes analysis, livers placed outside the United States (n = 10). Discard rates and graft outcomes were examined from cohorts 1 and 2, respectively. Of 5495 DCD livers recovered for transplant, 589 (10.7%) donors did not receive premortem heparin (no heparin) and the remaining 4906 (89.3%) received heparin (heparin). Liver discard was similar between the no heparin (30.6%) and heparin groups (30.8%; P = 0.90). Heparin status was not associated with liver discard on multivariate analysis (adjusted odds ratio, 0.97; 95% confidence interval [CI], 0.80-1.18 P = 0.76). The cumulative probability of overall graft survival was lower in the no heparin group relative to the heparin group (P < 0.05), and this finding persisted on multivariate analysis. No heparin group transplants had an 18% higher hazard of overall graft failure compared with those that received heparin (adjusted hazard ratio, 1.18; 95% CI, 1.01-1.38; P < 0.05). In conclusion, organ recovery heparin administration status was not associated with liver discard. Failure to pretreat organ donors with premortem heparin correlates with worse liver transplant graft survival compared with heparin-treated livers.

A Population-Based Study of 90-Day Hospital Cost and Utilization Associated With Robotic Surgery in Colon and Rectal Cancer.

BACKGROUND: The role of robotic surgery in colorectal cancer remains contentious with most data arising from small, single-institution studies. METHODS: Stage I-III colorectal cancer resections from 2008 to 2014 were identified in New York State. Propensity score-adjusted negative binomial models were used to compare cost and utilization between robotic, laparoscopic, and open resections. RESULTS: A total of 12,218 patients were identified. For colectomy, the robotic-to-open conversion rate was 3%, and the laparoscopic-to-open conversion rate was 13%. For rectal resection, the robotic-to-open conversion rate was 7% and the laparoscopic-to-open conversion rate was 32%. In intention-to-treat analysis, there was no significant difference in cost across the surgical approaches, both in overall and stratified analyses. Both laparoscopic and robotic approaches were associated with decreased 90-d hospital utilization compared with open surgery in intention-to-treat analyses. CONCLUSIONS: Robotic and laparoscopic colorectal cancer resections were not associated with a hospital cost benefit after 90 d compared with open but were associated with decreased hospital utilization. Conversion to open resection was common, and efforts should be made to prevent them. Future research should continue to measure how robotic and laparoscopic approaches can add value to the health care system.

Management of genitourinary foreign bodies in a predominantly incarcerated population.

INTRODUCTION Genitourinary foreign body (FB) insertion is a rare occurrence. Commonly reported reasons for insertion include autoeroticism and intoxication, however psychiatric illness is thought to contribute in most cases. In the incarcerated population, malingering plays a prominent role. We examined clinical patient characteristics and management patterns for cases of genitourinary FB insertion and sought to identify risk factors for recidivism. MATERIALS AND METHODS: A retrospective review was performed of all patients presenting to a tertiary trauma center with a genitourinary FB between January 2001-June 2019. Patient demographics, presentation, work up, and management were reviewed. Bivariate and multivariate statistical analyses were performed. RESULTS: Patients were primarily young (33 yo, range: 21-93), male (92%), incarcerated (67%), and had at least one psychiatric diagnosis (71%). Concomitant FB ingestion was present in 56 (41.5) encounters. Risk factors for repeat FB insertion included incarceration (100.0% versus 51.5%, p = < 0.01), psychiatric comorbidity (100.0% versus 51.5%, p = < 0.01), and other concomitant FB insertion/ingestion (68.7% versus 18.2%, p = < 0.01). Common methods of FB extraction included flexible cystoscopy (33.8%), extrinsic pressure (21.0%), rigid cystoscopy (12.8%), and open surgery (8.1%). Fifty-three (39.2%) encounters required anesthesia and 64 (47.4%) encounters required admission. CONCLUSIONS: Genitourinary FBs are usually removed via endoscopic or minimally invasive extraction techniques and the majority are located within the anterior urethra. Special consideration should be given to patients with psychiatric comorbidity, concomitant FB insertion/ingestion, or those presenting from a correctional facility as these characteristics are associated with repeat insertion attempts.

Normalizing inconvenience to promote childhood vaccination: a qualitative implementation evaluation of a novel Michigan program.

BACKGROUND: In 2015, Michigan implemented a rule requiring parents to attend an education session at a local health department (LHD) prior to waiving mandatory child vaccinations. This study utilizes Normalization Process Theory (NPT) to assess program implementation, identifying potential threats to fidelity and sustainability. METHODS: We conducted 32 semi-structured interviews with individuals involved in these education programs across 16 LHDs. Participating LHDs were selected from a stratified, representative sample. One interviewer conducted all interviews using a semi-structured interview guide; two authors coded and analyzed the interview transcripts according to the NPT framework (i.e, sense-making, engagement, collective action, and reflexive monitoring). RESULTS: There was a lack of consensus about who the stakeholders of this new rule and its resulting program were (sense-making). Perhaps as a result, most LHDs did not solicit advice from key stakeholder groups (i.e., schools, health care providers, community stakeholders) in their planning (engagement). While most interviewees identified providing education and information as the goal, some identified the more challenging goal of persuading vaccine hesitant parents to immunize their children. There was also some variation in perception of who held health educators accountable for meeting the goals of the waiver education program (collective action). Formal program evaluation by LHDs was rare, although some held informal staff debriefings. Additionally, sessions that went particularly well or poorly were top-of-mind (reflexive monitoring). CONCLUSIONS: The immunization waiver education program may be at risk of not becoming fully embedded into routine LHD practice, potentially compromising its long-term effectiveness and sustainability. Managers at the local and state level should maintain oversight to ensure that the program is delivered with fidelity. As the program relies on sustaining inconvenience to encourage parents to immunize their children, any shortcuts taken will undermine its success.

Surgeon, Hospital, and Geographic Variation in Minimally Invasive Colectomy.

OBJECTIVE: To identify sources of variation in the use of minimally invasive surgery (MIS) for colectomy. BACKGROUND: MIS is associated with decreased analgesic use, shorter length of stay, and faster postoperative recovery. This study identified factors explaining variation in MIS use for colectomy. METHODS: The Statewide Planning and Research Cooperative System was queried for scheduled admissions in which a colectomy was performed for neoplastic, diverticular, or inflammatory bowel disease between 2008 and 2015. Mixed-effects analyses were performed assessing surgeon, hospital, and geographic variation and factors associated with an MIS approach. RESULTS: Among 45,714 colectomies, 68.1% were performed using an MIS approach. Wide variation in the rate of MIS was present across 1253 surgeons (median 50%, interquartile range 10.9%-84.2%, range 0.3%-99.7%). Calculating intraclass correlation coefficients after controlling for case-mix, 62.8% of the total variation in MIS usage was attributable to surgeon variation compared with 28.5% attributable to patient variation, 7% attributable to hospital variation, and 1.6% attributable to geographic variation. Surgeon-years in practice since residency/fellowship completion explained 19.2% of the surgeon variation, surgeon volume explained 5.2%, hospital factors explained 0.1%, and patient factors explained 0%. CONCLUSIONS: Wide surgeon variation exists regarding an MIS approach for colectomy, and most of the total variation is attributable to individual surgeon practices-much of which is related to year of graduation. As increasing surgeon age is inversely proportional to the rate of MIS, patient referral and/or providing tailored training to older surgeons may be constructive targets in increasing the use of MIS and reducing healthcare utilization.

Outcomes of DCD kidneys recovered for transplantation with versus without pre-mortem heparin administration.

BACKGROUND: Pre-mortem heparin administration during donation after circulatory death (DCD) organ recovery may be particularly important to improve perfusion and prevent graft thrombosis. However, pre-mortem heparin administration is not universally practiced in the US and scarce data exist regarding its efficacy. METHODS: Using a national transplant registry data, we identified DCD kidneys recovered for transplantation from January 1, 2003, to March 10, 2017, and examined discard and outcomes after transplantation using bivariate and multivariable analyses. Organs with unknown or missing donor heparin status (n = 193), seropositive HIV (n = 10), HTLV (n = 33), hepatitis B (n = 26), or hepatitis C (n = 648) were excluded. RESULTS: Of 24 861 DCD kidneys recovered with (n = 22 557) or without pre-mortem heparin administration (n = 2304), discard occurred in 19.1% and 20.8%, respectively (P = 0.05). On multivariate analysis, heparin use was not associated with discard (aOR 1.02, 95% CI 0.89-1.17, P = 0.820). Overall graft survival of no-heparin (n = 1791) vs heparin groups (n = 17 968) was similar on univariate and multivariate analysis (aHR 0.98, 95% CI 0.87-1.09, P = 0.640). CONCLUSION: DCD kidneys from donors that have not received pre-mortem heparin administration have acceptable transplant outcomes and are not associated with discard.