Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium.

OBJECTIVE: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

Propensity Score Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta: Zone-1 Versus Zone-3 Resuscitative Endovascular Balloon Occlusion of the Aorta Odds of Mortality.

INTRODUCTION: There are two zones for the placement of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma patients: above the mesenteric vessels (Zone-1) or below the renal arteries (Zone-3). Zone-1 REBOA diverts blood away from the visceral organs which leads to a systemic inflammatory response and reperfusion injury. We hypothesized that patients undergoing Zone-1 REBOA placement had a higher odds of mortality. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for patients undergoing either Zone-1 or Zone-3 REBOA. We excluded all patients with prehospital cardiac arrest. We compared Zone-1 versus Zone-3 REBOA using a 1:2 propensity-score model, matching for age, mechanism, sex, hypotension, tachycardia, blunt solid organ injury grade, pelvic fracture, and injuries to the aorta, iliac artery, iliac vein, and inferior vena cava. RESULTS: We matched 130 Zone-1 REBOA patients to 260 Zone-3 REBOA patients. There were no statistically significant differences in the matched variables (P > 0.05). Compared to Zone-3 REBOA, patients with Zone-1 REBOA who survived ≥48 h had similar rates of acute kidney injury (18.6% versus 10.9%, P = 0.19). Zone-1 REBOA patients had a higher mortality rate (71.4% versus 48.8%, P = 0.002) and mortality odds ratio (OR) (OR 1.85, OR 1.18-2.89, P = 0.007). Zone-1 REBOA remained associated with a higher odds of mortality after controlling for traumatic brain injury and injury severity score (OR 1.86, OR 1.18-2.92, P = 0.007). CONCLUSIONS: Compared to Zone-3, using a REBOA in Zone-1 is associated with higher odds of mortality. The use of REBOA Zone-1 deployment should be done with caution.

The Relationship Between the COVID-19 Pandemic and Pediatric Trauma.

INTRODUCTION: The COVID-19 pandemic created difficulties in access to care. There was also increased penetrating trauma in adults, which has been attributed to factors including increased firearm sales and social isolation. However, less is known about the relationship between the pandemic and pediatric trauma patients (PTPs). This study aimed to investigate the national incidence of penetrating trauma in PTPs, hypothesizing a higher rate with onset of the pandemic. We additionally hypothesized increased risk of complications and death in penetrating PTPs after the pandemic versus prepandemic. METHODS: We included all PTPs (aged ≤17-years-old) from the 2017-2020 Trauma Quality Improvement Program database, dividing the dataset into two eras: prepandemic (2017-2019) and pandemic (2020). We performed subset analyses of the pandemic and prepandemic penetrating PTPs. Bivariate analyses and a multivariable logistic regression analysis were performed. RESULTS: Of the 474,524 PTPs, 123,804 (26.1%) were from the pandemic year. The pandemic era had increased stab wounds (3.3% versus 2.8%, P > 0.001) and gunshot wounds (5.5% versus 4.0%, P < 0.001) compared to the prepandemic era. Among penetrating PTPs, the rates and associated risk of in-hospital complications (2.6% versus 2.8%, P = 0.23) (odds ratio 0.90, confidence interval 0.79-1.02, P = 0.11) and mortality (4.9% versus 5.0%, P = 0.58) (odds ratio 0.90, confidence interval 0.78-1.03, P = 0.12) were similar between time periods. CONCLUSIONS: This national analysis confirms increased penetrating trauma, particularly gunshot wounds in pediatric patients following onset of the COVID-19 pandemic. Despite this increase, there was no elevated risk of death or complications, suggesting that trauma systems adapted to the "dual pandemic" of COVID-19 and firearm violence in the pediatric population.

Blunt Adrenal Injury is Not Associated With Worse Outcomes in Adult Trauma Patients.

INTRODUCTION: Blunt adrenal injury is rare. Given production of hormones including catecholamines, adrenal injury may lead to worse outcomes. However, there is a paucity of literature on this topic. As such, we compared blunt trauma patients (BTPs) with and without adrenal injuries, hypothesizing similar mortality and complications between cohorts. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adult (≥18-year-old) BTPs. Patients with penetrating trauma, traumatic brain injury, severe thoracic injury, or who were transferred from another hospital were excluded. Patients with adrenal injury were compared to those without using a 1:2 propensity score model. Matched variables included patient age, comorbidities, vitals on admission and concomitant injuries (i.e., liver, spleen, kidney, pancreas, and hollow viscus). Univariable logistic regression was then performed for associated risk of mortality. RESULTS: 2287 (0.2%) BTPs had an adrenal injury, with 1470 patients with adrenal injury matched to 2940 without adrenal injury. The rate of all complications including sepsis (0.1% versus 0.0%) was similar between cohorts (all P > 0.05). Patients with adrenal injury had a lower rate of mortality (0.1% versus 0.6%, P = 0.035) but increased length of stay (4 [3-6] versus 3 [2-5] days, P = 0.002). However, there was no difference in associated risk of mortality for patients with and without adrenal injury (odds ratio = 0.234; confidence interval = 0.54-1.015; P = 0.052). CONCLUSIONS: Blunt adrenal injury occurred in <1% of patients. After propensity matching, there was a similar associated rate of complications but longer hospital length of stay for patients with adrenal injury. Adrenal injury was not associated with an increased risk of mortality.

Is Adolescent Obesity Associated With a Higher Risk for Pelvic Fractures in Motor Vehicle Collisions?

INTRODUCTION: The impact of obesity on the incidence of blunt pelvic fractures in adults is unclear, and adolescents may have an increased risk of fracture due to variable bone mineral density and leptin levels. Increased subcutaneous adipose tissue may provide protection, though the association between obesity and pelvic fractures in adolescents has not been studied. This study hypothesized that obese adolescents (OAs) presenting after motor vehicle collision (MVC) have a higher rate of pelvic fractures, and OAs with such fractures have a higher associated risk of complications and mortality compared to non-OAs. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for adolescents (12-16 y old) presenting after MVC. The primary outcome was a pelvic fracture. Adolescents with a body mass index ≥30 (OA) were compared to adolescents with a body mass index <30 (non-OA). Subgroup analyses for high-risk and low-risk MVCs were performed. Multivariable logistic regression analyses were also performed adjusting for age and sex. RESULTS: From 22,610 MVCs, 3325 (14.7%) included OAs. The observed rate of pelvic fracture was similar between all OA and non-OA MVCs (10.2% versus 9.4%, P = 0.16), as well as subanalyses of minor or high-risk MVC (both P > 0.05). OAs presenting with a pelvic fracture after high-risk MVC had a similar risk of complications, pelvic surgery, and mortality compared to non-OAs (all P > 0.05). However, OAs with a pelvic fracture after minor MVC had a higher associated risk of complications (OR 2.27, CI 1.10-4.69, P = 0.03), but a similar risk of requiring pelvic surgery, and mortality (all P > 0.05). CONCLUSIONS: This national analysis found a similar observed incidence of pelvic fractures for OAs versus non-OAs involved in an MVC, including subanalyses of minor and high-risk MVC. Furthermore, there was no difference in the associated risk of morbidity and mortality except for OAs involved in a minor MVC had a higher risk of complication.

Inpatient Outcomes of Intercostal Nerve Cryoablation With Surgical Rib Fixation.

INTRODUCTION: Rib fractures are associated with significant pain and morbidity. Intercostal nerve cryoablation (INCA) offers targeted, prolonged pain relief for these patients. Over the last decade, more patients have undergone surgical stabilization of rib fractures (SSRF) after injury. However, data on INCA use in SSRF patients are limited. This study aimed to identify the relationship of INCA in blunt trauma patients (BTPs) undergoing SSRF, hypothesizing INCA coupled with SSRF would decrease hospital length of stay (LOS). METHODS: The Trauma Quality Improvement Program database (2017-2021) was queried for BTPs ≥18 y old who underwent SSRF. Patients who received INCA ((+)INCA) were compared to patients who did not ((-)INCA). The primary outcome was LOS. Secondary outcomes included intensive care unit (ICU) LOS and in-hospital complications. A subgroup analysis of only flail chest patients was performed. RESULTS: From 15,784 BTPs, 750 (4.8%) received INCA. Hospital LOS was similar between groups (12 versus 12 d, P = 0.10); however, the (+)INCA patients had decreased ICU LOS (6 versus 7 d, P < 0.001). The (+)INCA cohort also had decreased hospital complications (20.4% versus 24.4%, P = 0.01), including pulmonary embolism (0.7% versus 1.8%, P = 0.02) and ventilator-associated pneumonia (2.1% versus 3.8%, P = 0.02). On subgroup analysis of flail chest patients, decreased ICU LOS in the (+)INCA patients remained a significant outcome (7 versus 8 d, P = 0.02). CONCLUSIONS: Nearly 5% of SSRF patients received INCA. While overall LOS was similar, the (+)INCA cohort had decreased ICU LOS and in-hospital complications. Future studies are needed to corroborate these findings and evaluate any long-term complications associated with INCA before widespread adoption.

Mild and Severe Blood Alcohol Concentration Effects on Trauma and Traumatic Brain Injury Outcomes.

INTRODUCTION: Reported outcomes for trauma patients (TPs) with elevated blood alcohol concentration (BAC) have been mixed. Previous studies suggest that positive BAC might lead to lower venous thromboembolism (VTE) rates and mortality. This study expands upon these findings by examining the association of various levels of BAC, with additional emphasis on traumatic brain injury (TBI) patients. We hypothesize that both mild and severe-BAC levels in TPs are associated with decreased risk of VTE and mortality. METHODS: A retrospective review of the 2017 Trauma Quality Improvement Program was performed on adults (≥18 y old) screened for BAC on admission. Patients deceased on arrival and positive for drugs were excluded. We compared three groups: no-BAC, mild-BAC (0-70 mg/dL), and-severe BAC (>80 mg/dL) for associated risk of VTE and mortality. RESULTS: From 203,535 tested patients, 118,427 (58.2%) had no-BAC, 19,813 (9.7%) had mild-BAC, and 65,295 (32.1%) had severe-BAC. The associated risk of VTE was lower for mild-BAC (odds ratios [OR] 0.69, 0.58-0.82, P < 0.001) and severe-BAC (OR 0.80, 0.72-0.89, P < 0.001). This persisted in TBI patients, with mild-BAC (OR 0.67, 0.51-0.89, P = 0.006) and severe-BAC (OR 0.75, 0.64-0.89, P < 0.001) groups exhibiting lower associated VTE risk. However, the associated mortality risk was lower only in severe-BAC patients (OR 0.90, 0.83-0.97, P = 0.009). CONCLUSIONS: A positive BAC is linked to a reduced associated risk of VTE in TPs, including those with TBI. Notably, only the severe-BAC group demonstrated a lower associated risk of mortality. This merits future research including identification of basic science pathways that may be targeted to improve outcomes.

Defining the Disparity: A Multi-Institutional Analysis of Factors Associated With Decreased Resident Operative Experience.

INTRODUCTION: Technical learning in surgical training is multifaceted and existing literature suggests a positive relationship between case volume and proficiency. Little is known about factors associated with a decreased volume of operative experience. This study aimed to identify resident and program factors associated with general surgery residents (GSR) in the bottom quartile of logged case volume upon program completion. METHODS: A post hoc analysis of a multicenter study was used to examine case logs for categorical GSR. Participants included graduates between 2010 and 2020 from 20 programs. Residents below and above the 25th percentile for total operative volume were compared. RESULTS: The present study includes 1343 GSR who graduated over the 11-y period. In total, 336 residents were below the 25th percentile and 1007 residents were above the 25th percentile. Those below the 25th percentile were more likely to be female (41% versus 34%, P = 0.02), identify as underrepresented in medicine (22% versus 14%, P < 0.01), and pursue fellowship (86% versus 80%, P = 0.01) compared to those above the 25th percentile. Residents below the 25th percentile were more likely to have graduated from a low volume program (55% versus 25%, P < 0.01) and from top National Institutes of Health funded institutions (57% versus 52%, P = 0.01). CONCLUSIONS: This study identified individual and program characteristics associated with lower operative volume of GSR. Understanding such characteristics will aid surgical educators to achieve better equity in training.

Multisociety research collaboration: timing of cholecystectomy following cholecystostomy drainage for acute cholecystitis.

BACKGROUND: Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events. METHODS: This was a retrospective (2018-2020) multicenter study at 8 participating hospital systems of adult patients with AC, managed with PC and interval cholecystectomy. Demographics, comorbidities, treatment details, and outcomes were examined. Patients were grouped based on quartiles for timing of surgery after PC (< 7, 7-9, 10-13, > 13 weeks). The primary outcome was a composite endpoint of bile duct injury, reoperation, readmission, image-guided intervention, endoscopic intervention, conversion to open surgery, or death. RESULTS: There were 188 patients with a median age of 66 years with AC classified as mild (41%), moderate (47%), and severe (12%). Median days from PC to surgery were 65 (Q1 = 48, Q3 = 91). Laparoscopic cholecystectomy (89.9%) was the most commonly planned approach (robotic 6.4%, 3.7% open) and 28 (14.9%) were converted to open. The composite endpoint was reported in 51 patients (27.1%). A biliary injury occurred in 7 (3.7%) patients. Time to surgery and intraoperative drain placement were independently associated with the composite outcome. Cholecystectomy within 7 weeks of PC was associated with decreased risk (OR = 0.36, 95% CI 0.13-0.97) of the composite endpoint, compared to patients undergoing surgery > 13 weeks after PC. CONCLUSION: Timing of surgery following PC was associated with procedural outcomes. Patients undergoing surgery before 7 weeks experienced significantly less morbidity than patients having delayed cholecystectomy. These results should be considered in patient selection and management after PC.

Increased Mortality in Octogenarians Undergoing Endovascular Aortic Aneurysm Repair for Smaller Aneurysms Warrants Caution.

BACKGROUND: Geriatric patients constitute a growing portion of the general population, with particular increase in the prevalence of octogenarians. The incidence and prevalence of abdominal aortic aneurysms (AAAs) have been clearly shown to be associated with advancing age. The effect of advanced age in outcomes from endovascular aneurysm repair (EVAR) is unclear. We study the effect of advanced age, as an independent risk factor for mortality in octogenarian geriatric patients (OGPs) compared to nonoctogenarian geriatric patients (NOGPs) undergoing EVAR. METHODS: The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Procedure-Targeted Vascular database was queried for geriatric patients (>65 years) undergoing EVAR for symptomatic and asymptomatic indications. A multivariable logistic regression analysis was performed comparing outcomes between OGPs and NOGPs. RESULTS: Of the 10,490 geriatric patients who underwent EVAR, 7,508 (71.6%) were NOGPs and 2,982 (28.4%) were OGPs. Octogenarians were more often female (82.3% vs. 76.7%). In comparison to NOGPs, fewer OGPs were treated for AAA <5.5 cm (46.7% vs. 54.9%, P < 0.001) and AAA <5.0 cm (19.2% vs. 24.0%, P < 0.001). Nearly 90% of male and over 80% of female NOGPs and OGPs treated for AAA <5.0 cm were asymptomatic. Octogenarian geriatric patients (OGPs) had less dyspnea (15.3% vs. 17.3%, P = 0.01), chronic obstructive pulmonary disease (16.1% vs. 20.5%, P < 0.001), diabetes (12.7% vs. 17.8%, P < 0.001), and smoking (13.2% vs. 36.3%, P < 0.001) compared to NOGPs. Octogenarian geriatric patients (OGPs) were found to have a greater length of stay (2 days vs. 1 day, P < 0.001), as well as rate of mortality (3.4% vs. 1.7%, P < 0.001). Both symptomatic and asymptomatic OGPs had a higher rate of mortality than their NOGP counterparts (symptomatic 16% vs. 9.5%, P < 0.001; asymptomatic 1.3% vs. 0.5%, P < 0.001). Multivariate logistic regression analysis showed OGPs to have increased overall associated risk of mortality compared to NOGPs (odds ratio (OR) 1.88, confidence interval (CI) 1.39-2.54, P < 0.001), as well as in the symptomatic (OR 1.54, CI 1.06-2.23, P < 0.001) and asymptomatic cohorts (OR 2.66, CI 1.59-4.45, P < 0.001). CONCLUSIONS: Octogenarian geriatric patients (OGPs) accounted for over a quarter of geriatric patients undergoing EVAR. This elderly group was associated with an increased rate and risk of mortality compared to NOGPs, even when controlling for known risk factors for mortality. Given this increased risk of mortality in OGPs undergoing EVAR, elective treatment of AAAs in this advanced age group should be performed with caution, particularly in those with diameters in which the risk of rupture may not warrant repair.

Safety/booster seats in pediatric motor vehicle crashes: Public health concern.

INTRODUCTION: The American Academy of Pediatrics (AAP) guidelines recommend that children ≤12-years-old with height < 145 cm should use safety/booster seats. However, national adherence and clinical outcomes for eligible children involved in motor vehicle collisions (MVCs) are unknown. We hypothesized that children recommended to use safety/booster seats involved in MVCs have a lower rate of serious injuries if a safety/booster seat is used, compared to children without safety/booster seat. METHODS: This retrospective cohort study queried the 2017-2019 Trauma Quality Improvement Program database for patients ≤12-years-old and <145 cm (recommendation for use of safety/booster seat per American Academy of Pediatrics) presenting after MVC. Serious injury was defined by abbreviated injury scale grade ≥3 for any body-region. High-risk MVC was defined by authors in conjunction with definitions provided by the Centers for Disease Control and Prevention and the American College of Surgeons Committee on Trauma. RESULTS: From 8259 cases, 41% used a safety/booster seat. There was no difference in overall rate of serious traumatic injuries or mortality (both p > 0.05) between the safety/booster seat and no safety/booster seat groups. In a subset analysis of high-risk MVCs, the overall use of safety/booster seats was 56%. The rate of serious traumatic injury (53.6% vs. 62.1%, p = 0.017) and operative intervention (15.8% vs. 21.6%, p = 0.039) was lower in the safety/booster seat group compared to the no safety/booster seat group. CONCLUSIONS: Despite AAP guidelines, less than half of recommended children in our study population presenting to a trauma center after MVC used safety/booster seats. Pediatric patients involved in a high-risk MVC suffered more serious injuries and were more likely to require surgical intervention without a safety/booster seat. A public health program to increase adherence to safety/booster seat use within this population appears warranted.

Significant variation in computed tomography imaging of pregnant trauma patients: a retrospective multicenter study.

PURPOSE: Following motor vehicle collisions (MVCs), patients often undergo extensive computed tomography (CT) imaging. However, pregnant trauma patients (PTPs) represent a unique population where the risk of fetal radiation may supersede the benefits of liberal CT imaging. This study sought to evaluate imaging practices for PTPs, hypothesizing variability in CT imaging among trauma centers. If demonstrated, this might suggest the need to develop specific guidelines to standardize practice. METHODS: A multicenter retrospective study (2016-2021) was performed at 12 Level-I/II trauma centers. Adult (≥18 years old) PTPs involved in MVCs were included, with no patients excluded. The primary outcome was the frequency of CT. Chi-square tests were used to compare categorical variables, and ANOVA was used to compare the means of normally distributed continuous variables. RESULTS: A total of 729 PTPs sustained MVCs (73% at high speed of ≥ 25 miles per hour). Most patients were mildly injured but a small variation of injury severity score (range 1.1-4.6, p < 0.001) among centers was observed. There was a variation of imaging rates for CT head (range 11.8-62.5%, p < 0.001), cervical spine (11.8-75%, p < 0.001), chest (4.4-50.2%, p < 0.001), and abdomen/pelvis (0-57.3%, p < 0.001). In high-speed MVCs, there was variation for CT head (12.5-64.3%, p < 0.001), cervical spine (16.7-75%, p < 0.001), chest (5.9-83.3%, p < 0.001), and abdomen/pelvis (0-60%, p < 0.001). There was no difference in mortality (0-2.9%, p =0.19). CONCLUSION: Significant variability of CT imaging in PTPs after MVCs was demonstrated across 12 trauma centers, supporting the need for standardization of CT imaging for PTPs to reduce unnecessary radiation exposure while ensuring optimal injury identification is achieved.

Analysis of Veno-Venous Extracorporeal Membrane Oxygenation for COVID-19 Compared to Non-COVID Etiologies.

OBJECTIVE: This study analyzed the characteristics and outcomes of veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) due to COVID-19 versus non-COVID causes at US academic centers. BACKGROUND DATA: V-V ECMO support has been utilized for COVID-19 patients with ARDS since the beginning of the pandemic. Mortality for ECMO in COVID-19 has been reported to be high but similar to reported mortality for ECMO support for non-COVID causes of respiratory failure. METHODS: Using ICD-10 codes, data of patients who underwent V-V ECMO for COVID-19 ARDS were compared with patients who underwent V-V ECMO for non-COVID causes between April 2020 and December 2022. The primary outcome was in-hospital mortality. Secondary outcome measures included length of stay and direct cost. Multivariate logistic regression modeling was performed to analyze differences in mortality between COVID and non-COVID groups, adjusting for other important risk factors (age, sex, and race/ethnicity). RESULTS: We identified and compared 6382 patients who underwent V-V ECMO for non-COVID causes to 6040 patients who underwent V-V ECMO for COVID-19. There was a significantly higher proportion of patients aged ≥ 65 years who underwent V-V ECMO in the non-COVID group compared with the COVID group (19.8% vs. 3.7%, respectively, P <0.001). Compared with patients who underwent V-V ECMO for non-COVID causes, patients who underwent V-V ECMO for COVID had increased in-hospital mortality (47.6% vs. 34.5%, P <0.001), length of stay (46.5±41.1 days vs. 40.6±46.1, P <0.001), and direct hospitalization cost ($207,022±$208,842 vs. $198,508±205,510, P =0.02). Compared with the non-COVID group, the adjusted odds ratio (OR) for in-hospital mortality in the COVID group was 2.03 (95% CI: 1.87-2.20, P <0.001). In-hospital mortality for V-V ECMO in COVID-19 improved during the study time period (50.3% in 2020, 48.6% in 2021, and 37.3% in 2022). However, there was a precipitous drop in the ECMO case volume for COVID starting in quarter 2 of 2022. CONCLUSIONS: In this nationwide analysis, COVID-19 patients with ARDS requiring V-V ECMO support had increased mortality compared with patients who underwent V-V ECMO for non-COVID etiologies.

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium.

OBJECTIVE: To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

Firearm Violence Surrounding the COVID-19 Pandemic: A Reopening Phenomenon.

INTRODUCTION: Past research has demonstrated a "reopening phenomenon" of increased firearm violence associated with the initial lifting of coronavirus disease 2019 (COVID-19) pandemic-related restrictions after the first wave. Now, with widespread societal reemergence from stay-at-home measures, we hypothesize another spike in firearm violence in the United States (US). Thus, the purpose of this study was to evaluate the trends in firearm violence before and after extensive community reopenings during the COVID-19 pandemic. METHODS: The Gun Violence Archive was utilized to collect data on daily firearm violence incidents, injuries, and deaths as well as on types of firearm violence. Mann-Whitney U-tests were performed for trends and types of firearm violence "before" (12/14/20-4/9/21) versus "after" (4/10/21-7/31/21) widespread societal reopening in the US. Additional analyses also sought to compare the after reopening time-period to historical data (2017-2020) of similar calendar dates, to better control for possible annual/seasonal variation. RESULTS: Median daily firearm violence incidents (153 versus 176, P < 0.001), injuries (89 versus 121, P < 0.001) and deaths (54 versus 58, P < 0.001) increased from before versus after reopening. Compared to all historical years, in the after reopening time-period there were consistent increases in total as well as mass shooting incidents/injuries/deaths (all P < 0.05). CONCLUSIONS: Firearm violence incidents, injuries, and deaths increased after societal reemergence from the COVID-19 pandemic. In addition, there has been an increase in mass shootings despite a relative lull initially brought on by the pandemic. This suggests the "reopening phenomenon" has worsened an already substantial national firearm epidemic.

Scoring Tool to Predict Need for Early Video-Assisted Thoracoscopic Surgery (VATS) After Pediatric Trauma.

BACKGROUND: No widely used stratification tool exists to predict which pediatric trauma patients may require a video-assisted thoracoscopic surgery (VATS). We sought to develop a novel VATS-In-Pediatrics (VIP) score to predict the need for early VATS (within 72 h of admission) for pediatric trauma patients. METHODS: The pediatric 2017-2020 Trauma Quality Improvement Program database was used and divided into two sets (derivation set using 2017-2019 data and validation set using 2020 data). First, multiple logistic regression models were created to determine the risk of early VATS for patients ≤ 17 years old. Second, the weighted average and relative impact of each independent predictor were used to derive a VIP score. We then validated the score using the area under the receiver operating characteristic (AROC) curve. RESULTS: From 218,628 patients in the derivation set, 2183 (1.0%) underwent early VATS. A total of 8 independent predictors of VATS were identified, and the VIP score was derived with scores ranging from 0 to 9. The AROC for this was 0.91. The VATS rate increased steadily from 12.5 to 32% then 60.5% at scores of 3, 4, and 6, respectively. In the validation set, from 70,316 patients, 887 (1.3%) underwent VATS, and the AROC was 0.91. CONCLUSIONS: VIP is a novel and validated scoring tool to predict the need for early VATS in pediatric trauma. This tool can potentially help hospital systems prepare for pediatric patients at high risk for requiring VATS during their first 72 h of admission. Future prospective research is needed to evaluate VIP as a tool that can improve clinical outcomes.

A Prospective Multicenter Comparison of Trauma and Injury Severity Score, American Society of Anesthesiologists Physical Status, and National Surgical Quality Improvement Program Calculator's Ability to Predict Operative Trauma Outcomes.

BACKGROUND: Trauma outcome prediction models have traditionally relied upon patient injury and physiologic data (eg, Trauma and Injury Severity Score [TRISS]) without accounting for comorbidities. We sought to prospectively evaluate the role of the American Society of Anesthesiologists physical status (ASA-PS) score and the National Surgical Quality Improvement Program Surgical Risk-Calculator (NSQIP-SRC), which are measurements of comorbidities, in the prediction of trauma outcomes, hypothesizing that they will improve the predictive ability for mortality, hospital length of stay (LOS), and complications compared to TRISS alone in trauma patients undergoing surgery within 24 hours. METHODS: A prospective, observational multicenter study (9/2018-2/2020) of trauma patients ≥18 years undergoing operation within 24 hours of admission was performed. Multiple logistic regression was used to create models predicting mortality utilizing the variables within TRISS, ASA-PS, and NSQIP-SRC, respectively. Linear regression was used to create models predicting LOS and negative binomial regression to create models predicting complications. RESULTS: From 4 level I trauma centers, 1213 patients were included. The Brier Score for each model predicting mortality was found to improve accuracy in the following order: 0.0370 for ASA-PS, 0.0355 for NSQIP-SRC, 0.0301 for TRISS, 0.0291 for TRISS+ASA-PS, and 0.0234 for TRISS+NSQIP-SRC. However, when comparing TRISS alone to TRISS+ASA-PS (P = .082) and TRISS+NSQIP-SRC (P = .394), there was no significant improvement in mortality prediction. NSQIP-SRC more accurately predicted both LOS and complications compared to TRISS and ASA-PS. CONCLUSIONS: TRISS predicts mortality better than ASA-PS and NSQIP-SRC in trauma patients undergoing surgery within 24 hours. The TRISS mortality predictive ability is not improved when combined with ASA-PS or NSQIP-SRC. However, NSQIP-SRC was the most accurate predictor of LOS and complications.

Obese adolescents have higher risk for severe lower extremity fractures after falling.

INTRODUCTION: Reports vary on the impact of obesity on the incidence of lower extremity fractures after a fall. We hypothesized that obese adolescents (OA) presenting after a fall have a higher risk of any and severe lower extremity fractures compared to non-OAs. METHODS: A national database was queried for adolescents (12-17 years old) after a fall. Primary outcome included lower extremity fracture. Adolescents with a body mass index (BMI) ≥ 30 (OA) were compared to adolescents with a BMI < 30 (non-OA). RESULTS: From 20,264 falls, 2523 (12.5%) included OAs. Compared to non-OAs, the rate of any lower extremity fracture was higher for OAs (51.5% vs. 30.7%, p < 0.001). This remained true for lower extremity fractures at all locations (all p < 0.05). After adjusting for sex and age, associated risk for any lower extremity fracture (OR 2.41, CI 2.22-2.63, p < 0.001) and severe lower extremity fracture (OR 1.31, CI 1.15-1.49, p < 0.001) was higher for OAs. This remained true in subset analyses of ground level falls (GLF) and falls from height (FFH) (all p < 0.05). CONCLUSIONS: Obesity significantly impacts adolescents' risk of all types of lower extremity fractures after FFH or GLF. Hence, providers should have heightened awareness for possible lower extremity fractures in OAs. LEVEL OF EVIDENCE: IV.

Risk factors and outcomes in pediatric blunt cardiac injuries.

PURPOSE: Unlike adults, less is known of the etiology and risk factors for blunt cardiac injury (BCI) in children. Identifying risk factors for BCI in pediatric patients will allow for more specific screening practices following blunt trauma. METHODS: A retrospective review was performed using the Trauma Quality Improvement Program (TQIP) database from 2017 to 2019. All patients ≤ 16 years injured following blunt trauma were included. Demographics, mechanism, associated injuries, injury severity, and outcomes were collected. Univariate and multivariate regression was used to determine specific risk factors for BCI. RESULTS: Of 266,045 pediatric patients included in the analysis, the incidence of BCI was less than 0.2%. The all-cause mortality seen in patients with BCI was 26%. Motor-vehicle collisions (MVCs) were the most common mechanism, although no association with seatbelt use was seen in adolescents (p = 0.158). The strongest independent risk factors for BCI were pulmonary contusions (OR 15.4, p < 0.001) and hemothorax (OR 8.9, p < 0.001). CONCLUSIONS: Following trauma, the presence of pulmonary contusions or hemothorax should trigger additional screening investigations specific for BCI in pediatric patients.

Impact of easing COVID-19 safety measures on trauma computed tomography imaging volumes.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has led to substantial disruptions in healthcare staffing and operations. Stay-at-home (SAH) orders and limitations in social gathering implemented in spring 2020 were followed by initial decreases in healthcare and imaging utilization. This study aims to evaluate the impact of subsequent easing of SAH on trauma volumes, demand for, and turnaround times for trauma computed tomography (CT) exams, hypothesizing that after initial decreases, trauma volumes have increased as COVID safety measures have been reduced. METHODS: Patient characteristics, CT imaging volumes, and turnaround time were analyzed for all adult activated emergency department trauma patients requiring CT imaging at a single Level-I trauma center (1/2018-2/2022) located in the sixth most populous county in the USA. Based on COVID safety measures in place in the state of California, three time periods were compared: baseline (PRE, 1/1/2018-3/19/2020), COVID safety measures (COVID, 3/20/2020-1/25/2021), and POST (1/26/2021-2/28/2022). RESULTS: There were 16,984 trauma patients across the study (PRE = 8289, COVID = 3139, POST = 5556). The average daily trauma patient volumes increased significantly in the POST period compared to the PRE and COVID periods (13.9 vs. 10.3 vs. 10.1, p < 0.001), with increases in both blunt (p < 0.001) and penetrating (p = 0.002) trauma. The average daily number of trauma CT examinations performed increased significantly in the POST period compared to the PRE and COVID periods (56.7 vs. 48.3 vs. 47.6, p < 0.001), with significant increases in average turnaround time (47 min vs. 31 and 37, p < 0.001). CONCLUSION: After initial decreases in trauma radiology volumes following stay-at-home orders, subsequent easing of safety measures has coincided with increases in trauma imaging volumes above pre-pandemic levels and longer exam turnaround times.