Unspoken Truths: Mental Health Among Academic Surgeons.

OBJECTIVE: To characterize the current state of mental health within the surgical workforce in the United States. BACKGROUND: Mental illness and suicide is a growing concern in the medical community; however, the current state is largely unknown. METHODS: Cross-sectional survey of the academic surgery community assessing mental health, medical error, and suicidal ideation. The odds of suicidal ideation adjusting for sex, prior mental health diagnosis, and validated scales screening for depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol use disorder were assessed. RESULTS: Of 622 participating medical students, trainees, and surgeons (estimated response rate=11.4%-14.0%), 26.1% (141/539) reported a previous mental health diagnosis. In all, 15.9% (83/523) of respondents screened positive for current depression, 18.4% (98/533) for anxiety, 11.0% (56/510) for alcohol use disorder, and 17.3% (36/208) for PTSD. Medical error was associated with depression (30.7% vs. 13.3%, P <0.001), anxiety (31.6% vs. 16.2%, P =0.001), PTSD (12.8% vs. 5.6%, P =0.018), and hazardous alcohol consumption (18.7% vs. 9.7%, P =0.022). Overall, 13.2% (73/551) of respondents reported suicidal ideation in the past year and 9.6% (51/533) in the past 2 weeks. On adjusted analysis, a previous history of a mental health disorder (aOR: 1.97, 95% CI: 1.04-3.65, P =0.033) and screening positive for depression (aOR: 4.30, 95% CI: 2.21-8.29, P <0.001) or PTSD (aOR: 3.93, 95% CI: 1.61-9.44, P =0.002) were associated with increased odds of suicidal ideation over the past 12 months. CONCLUSIONS: Nearly 1 in 7 respondents reported suicidal ideation in the past year. Mental illness and suicidal ideation are significant problems among the surgical workforce in the United States.

Using the Social Vulnerability Index to Analyze Statewide Health Disparities in Cholecystectomy.

INTRODUCTION: Addressing the effects of social determinants of health in surgery has become a national priority. We evaluated the utility of the Social Vulnerability Index (SVI) in determining the likelihood of receiving cholecystectomy for cholecystitis in Texas. METHODS: A retrospective study of adults with cholecystitis in the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Data Public Use Data File from 2016 to 2019. Patients were stratified into SVI quartiles, with the lowest quartile as low vulnerability, the middle two as average vulnerability, and the highest as high vulnerability. The relative risk (RR) of undergoing surgery was calculated using average vulnerability as the reference category and subgroup sensitivity analyses. RESULTS: A total of 67,548 cases were assessed, of which 48,603 (72.0%) had surgery. Compared with the average SVI groups, the low vulnerability groups were 21% more likely to undergo cholecystectomy (RR = 1.21, 95% confidence interval [CI] 1.18-1.24), whereas the high vulnerability groups were 9% less likely to undergo cholecystectomy (RR = 0.91, 95% CI 0.88-0.93). The adjusted model showed similar results (RR = 1.05, 95% CI 1.04-1.06 and RR = 0.97, 95% CI 0.96-0.99, for low and high vulnerability groups, respectively). These results remained significant after stratifying for age, sex, ethnicity, and insurance status. However, the differences between low, average, and high vulnerability groups diminished in rural settings, with lower surgery rates in all groups. CONCLUSIONS: Patients with higher SVI were less likely to receive an elective cholecystectomy. SVI is an effective method of identifying social determinants impacting access to and receipt of surgical care.

Adoption of Robotic Adrenalectomy: A Two-Institution Study of Surgeon Learning Curve.

BACKGROUND: Robotic adrenalectomy is feasible and safe, yet concerns over increased operative times and the learning curve (LC) for proficiency have limited its adoption. This study aimed to assess the LC for robotic adrenalectomy. METHODS: This is a two-institution retrospective review of consecutive unilateral minimally invasive adrenalectomies performed by four high-volume adrenal surgeons between 2007 and 2022. Two surgeons transitioned from laparoscopic to robotic adrenalectomy, and two surgeons adopted the approach, with proctoring, after completion of fellowship training without robotic experience. Operative time and complications were analyzed. Multivariable regression was used to identify factors associated with operative time. The number of cases required to overcome the LC was determined using the LC-cumulative-sum (LC-CUSUM) analysis. RESULTS: Of 457 adrenalectomies, 182 (40%) were laparoscopic and 275 (60%) robotic. The robotic approach was associated with shorter median operative time (106 vs 119 min; p = 0.002), fewer complications (6% vs 13%; p = 0.018), and fewer conversions to open adrenalectomy (1% vs 4%; p = 0.030), with no difference between the senior and junior surgeons. On adjusted analysis, factors associated with increased operative time were male sex (p < 0.001), BMI > 30 kg/m2 (p < 0.001), and higher gland weight (p < 0.001). The LC-CUSUM analysis showed proficiency after 8-29 procedures. Compared with the first 10 cases, there was a mean reduction in operative time of 14 min after 10-20 cases, 28 min after 20-30 cases, and 29 min after > 30 cases, regardless of surgeon experience. DISCUSSION: With dedicated teams and proctoring, robotic adrenalectomy can be safely adopted at high-volume centers with a minimal LC.

Assessing the Complex General Surgical Oncology Pipeline: Trends in Race and Ethnicity Among US Medical Students, General Surgery Residents, and Complex General Surgical Oncology Trainees.

BACKGROUND: Cancer incidence is expected to increase in coming decades, disproportionately so among minoritized communities. Racially and ethnically concordant care is essential to addressing disparities in cancer outcomes within at-risk groups. Here, we assess trends in racial and ethnic representation of medical students (MS), general surgery (GS) residents, and complex general surgical oncology (CGSO) fellows. METHODS: This is a retrospective review of data from the American Association of Medical Colleges and the Accreditation Council of Medical Education (ACGME) from 2015 to 2020. Self-reported race and ethnicity was obtained for MS, GS, and CGSO trainees. Race and ethnicity proportions were compared with respective representation in the 2020 US Census. Mann-Kendall, Wilcoxon rank sum, and linear regression were used to assess trends, as appropriate. RESULTS: A total of 316,448 MS applicants, 128,729 MS matriculants, 27,574 GS applicants, 46,927 active GS residents, 710 CGSO applicants, and 659 active CGSO fellows were included. With every progressive stage in training, there was a smaller proportion of URM active trainees than applicants. Further, URM, Hispanic/Latino, and Black/African American trainees were significantly underrepresented compared with 2020 Census data. While the proportion of White CGSO fellows increased over time (54.5-69.2%, p = 0.009), the proportion of Black/African American and Hispanic/Latino (URM) CGSO fellows did not significantly change over the study period, though URM representation was lower in 2020 as compared with 2015. DISCUSSION: From 2015 to 2020, minority representation decreased at every advancing stage in surgical oncology training. Efforts to address barriers for URM applicants to CGSO fellowships are needed.

Post-COVID-19 Multisystem Inflammatory Syndrome-Related Cerebral Infarction in a Pediatric Patient Managed with Decompressive Craniectomy.

INTRODUCTION: Most people who are infected with the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are asymptomatic or present with mild upper respiratory symptoms. This is especially true in the pediatric population; however, rarely, a massive cytokine storm can develop, causing multisystem inflammatory syndrome associated with COVID (MIS-C). Furthermore, children may also suffer from acute ischemic strokes secondary to SARS-CoV-2 infection. CASE PRESENTATION: Here, we present a 2-year-old male who was admitted to the hospital with MIS-C and evidence of a previous SARS-CoV-2 infection. On postadmission day 2, the patient was in cardiogenic shock, had acute kidney injury, liver dysfunction, and metabolic acidosis. He had concurrent altered mental status, and his computed tomography scan showed ischemic infarcts in the territory of the right middle cerebral artery and superior cerebellar artery bilaterally. Magnetic resonance angiography confirmed occlusion of the right middle cerebral artery and right superior cerebellar artery. He underwent an emergent decompressive craniectomy due to rapid deterioration and cerebral edema. After the procedure, he continued to improve and was discharged with moderate disability that improved during outpatient rehab. CONCLUSION: Though rare in children, SARS-CoV-2 can lead to AIS, especially in the presence of underlying risk factors such as MIS-C and hypercoagulopathy. AIS can be associated with severe mortality and morbidity; however, even in this severe case of AIS, the patient was successfully treated with a decompressive craniectomy.

Sex Differences in Comorbidities of Pediatric Craniosynostosis at Presentation.

INTRODUCTION: Craniosynostosis is a common pediatric presentation in which the premature fusion of one or more cranial sutures results in a misshapen skull. This birth defect is often associated with comorbidities due to structural impacts on nearby anatomical features. While there is some evidence for a male predominance among craniosynostosis patients, little has been investigated regarding sex differences in comorbidities of this condition. This study seeks to explore potential sexual dimorphisms in craniosynostosis patients at the time of presentation. METHODS: We conducted a retrospective, cross-sectional review of male and female non-syndromic craniosynostosis (NSC) patients between the ages of 1 month and 9 years that were evaluated at a 500-bed academic hospital or a 977-bed private hospital in Lubbock, TX, USA. Common comorbidities including ophthalmologic diagnoses, developmental delays, obstructive sleep apnea, chronic otitis media, hearing loss, chronic headaches, and seizure disorders were evaluated. The NSC cohort was compared to a similarly aged trauma group that represented the normal population. RESULTS: 175 NSC patients fit the inclusion criteria, of which 109 (62%) were male. A diagnosis of craniosynostosis was significantly associated with ophthalmological diagnoses (p < 0.0001), chronic otitis media (p < 0.0001), developmental delays (p < 0.0001), and hearing loss (p = 0.0047). Male NSC patients were less likely to present with ophthalmological diagnoses (p = 0.0010) or hearing loss (p = 0.0052) than females. CONCLUSIONS: Our findings expand on current literature evaluating possible comorbidities of NSC, particularly supporting the association with ophthalmological diagnoses, chronic otitis media, developmental delays, and hearing loss. We also report sex differences in ophthalmological diagnoses and hearing loss for NSC patients. These findings can serve to educate physicians of symptoms requiring prompt recognition and management in these patients.

Crush injury with significant soft tissue loss managed utilising biological and dynamic tissue systems: a case study.

Major traumatic crush injuries are difficult to manage, with high morbidity, requiring prolonged, complex treatment with many procedures. Free-flap reconstruction is often used yet full functionality still may not be regained. In this case study of a traumatic crush injury of the anterior distal tibia, ankle and foot of a 48-year-old male patient, we opted for an alternative management strategy using a combination of a dynamic tissue system (DTS) and biological xenografts (porcine urinary bladder matrix and a multi-tissue platform). The DTS was kept in place in an outpatient setting for four weeks postoperatively and removed after that time. At the 3-month follow-up, the wound was significantly smaller at about 15% of the original size. The wound healed completely before 6-month follow-up. Our patient's traumatic crush injury was successfully healed using an alternative management strategy, DTS and biologic xenografts.

Use of a dynamic tissue system and biological xenograft in complex traumatic wound closure.

OBJECTIVE: Asymmetrical dimensions and nonlinear margins of a multilayered traumatic wound often preclude healing via primary intention. We present the case of an otherwise healthy 21-year-old male who sustained trauma following a boating accident. METHOD: The patient sustained three lacerations to the posterior thighs from the boat propeller. The most extensive wound measured 25×10×6cm of muscle extrusion with a divot fracture involving the posterior femur. RESULTS: Primary closure and restoration of muscle biomechanics was achieved using a combination of a dynamic tissue system (DTS) and porcine urinary bladder matrix (PUBM) xenograft. After 24 days of treatment in hospital, the patient was discharged without the need for home health, outpatient wound care, or ongoing negative pressure wound therapy. The patient recovered full function of the legs and was cleared for participation in all activities. CONCLUSION: This complex traumatic boat propeller injury presented many challenges, including a transverse orientation on the extremity, degree of muscle injury/extrusion, and significant soft tissue loss. The combined application of a DTS with PUBM biological xenograft achieved a primary myocutaneous closure without the need for skin graft or flap reconstruction by plastic surgery.

Association of social vulnerability with receipt of hernia repair in Texas.

BACKGROUND: The effect of social health determinants on hernia surgery receipt is unclear. We aimed to assess the association of the social vulnerability index with the likelihood of undergoing elective and emergency hernia repair in Texas. METHODS: This is a retrospective cohort analysis of the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Public Use Data File from 2016 to 2019. Patients ≥18 years old with inguinal or umbilical hernia were included. Social vulnerability index and urban/rural status were merged with the database at the county level. Patients were stratified based on social vulnerability index quartiles, with the lowest quartile (Q1) designated as low vulnerability, Q2 and Q3 as average, and Q4 as high vulnerability. Wilcoxon rank sum, t test, and χ2 analysis were used, as appropriate. The relative risk of undergoing surgery was calculated with subgroup sensitivity analysis. RESULTS: Of 234,843 patients assessed, 148,139 (63.1%) underwent surgery. Compared to patients with an average social vulnerability index, the low social vulnerability index group was 36% more likely to receive surgery (relative risk: 1.36, 95% CI 1.34-1.37), whereas the high social vulnerability index group was 14% less likely to receive surgery (relative risk: 0.86, 95% CI 0.85-0.86). This remained significant after stratifying for age, sex, insurance status, ethnicity, and urban/rural status (P < .05). For emergency admissions, there was no difference in receipt of surgery by social vulnerability index. CONCLUSION: Vulnerable patients are less likely to undergo elective surgical hernia repair, even after adjusting for demographics, insurance, and urbanicity. The social vulnerability index may be a useful indicator of social determinants of health barriers to hernia repair.

The impact of social determinants of health on thyroid cancer mortality and time to treatment.

BACKGROUND: Whereas racial disparities in thyroid cancer care are well established, the role of social determinants of health is less clear. We aimed to assess the individual and cumulative impact of social determinants of health on mortality and time to treatment among patients with thyroid cancer. METHODS: We collected social determinants of health data from thyroid cancer patients registered in the National Cancer Database from 2004 to 2017. We created a count variable for patients in the lowest quartile of each social determinant of health (ie, low income, low education, and no insurance). We assessed the association of social determinants of health with mortality and time to treatment and the association between cumulative social determinants of health count and time to treatment using Cox regression. RESULTS: Of the 142,024 patients we identified, patients with longer time to treatment had greater mortality compared to patients treated within 90 days (90-180 days, adjusted hazard ratio 1.21 (95% confidence interval 1.13-1.29, P < .001); >180 days, adjusted hazard ratio 1.57 (95% confidence interval 1.41-1.76, (P < .001). Compared to patients with no adverse social determinants of health, patients with 1, 2, or 3 adverse social determinants of health had a 10%, 12%, and 34%, respectively, higher likelihood of longer time to treatment (1 social determinant of health, hazard ratio 0.90, 95% confidence interval 0.89-0.92, P < .001; 2 social determinants of health, hazard ratio 0.88, 95% confidence interval 0.87-0.90, P < .001; 3 social determinants of health, hazard ratio 0.66, 95% confidence interval 0.62-0.71, P < .001 for all). On subgroup analysis by race, each adverse social determinant of health was associated with an increased likelihood of a longer time to treatment for Black and Hispanic patients (P < .05). CONCLUSION: A greater number of adverse social determinants of health leads to a higher likelihood of a longer time to treatment for patients with thyroid cancer, which, in turn, is associated with an increased risk for mortality.

Association of patient-practitioner sex concordance with specialist referral in primary hyperparathyroidism.

BACKGROUND: Prior research has demonstrated barriers to the workup and management of primary hyperparathyroidism. As recent data have suggested that patient and practitioner sex concordance is associated with lower surgical complications, we sought to evaluate the effect of sex concordance on referral for primary hyperparathyroidism. METHODS: We queried an institutional database for patients with first-incident hypercalcemia and subsequent biochemical evidence of primary hyperparathyroidism between 2010 and 2018. Primary care practitioner and endocrinologist sex, laboratory values, and complications of primary hyperparathyroidism were collected. Sex concordance (male patient/male practitioner or female patient/female practitioner) was evaluated as a binary predictor of specialist evaluation using logistic regression and Cox proportional hazards modeling. RESULTS: Among 1,100 patients, mean age was 62.5 (standard deviation 13.6), and 74% were female sex. Primary care practitioner sex was 52% female, and 63% of patients had sex concordance with their primary care practitioner. Endocrinologist sex was 59% female, and 45% of patients had sex concordance with their endocrinologist. Patients with sex concordance with their primary care practitioner (70 vs 80%, P = .001) and endocrinologist (71 vs 82%, P < .001) were less likely to be female sex compared to those with discordance. After adjusting for demographics and clinical covariates, those patients with primary care practitioner sex concordance had 32% higher odds of endocrinologist evaluation (odds ratio 1.32, 95% confidence interval 1.003-1.734, P = .047). Similarly, those patients with endocrinologist sex concordance had a 48% higher rate of surgeon evaluation (hazard ratio 1.48, confidence interval 1.1-2.0, P = .009). Stratified analysis revealed that sex discordance reduced the rate of surgeon referral for female patients (hazard ratio 0.63, confidence interval 0.44-0.89, P = .008) but not male patients (hazard ratio 1.06, CI 0.58-1.93, P = .861). CONCLUSION: Sex discordance between patients and their health care professionals may contribute to under-referral in primary hyperparathyroidism. Further evaluation of the effect of patient and practitioner identities on communication and decision-making in surgery are needed.

Social vulnerability and time to surgeon evaluation for primary hyperparathyroidism in a Massachusetts cohort.

BACKGROUND: Identifying patients at risk for under-evaluation of primary hyperparathyroidism is essential to minimizing long-term sequelae, including osteoporosis, nephrolithiasis, and cardiovascular disease. This study assessed the impact of social vulnerability on time-to-surgery evaluation among patients with primary hyperparathyroidism in a Massachusetts cohort. METHODS: This is a retrospective review of patients from an institutional database with the first incident of hypercalcemia between 2010 and 2018 and subsequent biochemical diagnosis of primary hyperparathyroidism. The overall social vulnerability index and social vulnerability index subthemes were merged with the institutional data via patient ZIP code. Patients were stratified into social vulnerability index quartiles, where quartile 4 represented the highest vulnerability. Baseline sociodemographic and clinical characteristics were compared, and Cox regression was used to assess the association between social vulnerability index and time to surgeon evaluation. RESULTS: Of 1,082 patients included, those with a higher social vulnerability index were less likely to be evaluated by a surgeon (quartile 1 social vulnerability index: 31.1% vs. quartile 2 social vulnerability index: 31.41% vs. quartile 3 social vulnerability index: 25.93% vs. quartile 4 social vulnerability index: 21.92%, P = .03). On adjusted analysis, patients with the highest vulnerability had a 33% lower estimated rate of surgeon evaluation and were seen 67 days later compared with patients with the lowest vulnerability (hazard ratio: 0.67, confidence interval 0.47-0.97, P = .032). Differential rates of surgical evaluation by vulnerability persisted for the social vulnerability index subthemes for socioeconomic status, minority status and language, and housing type and transportation. CONCLUSION: Among a Massachusetts cohort, highly vulnerable populations with primary hyperparathyroidism are at greater risk for under-evaluation by a surgeon, which may contribute to the development of long-term sequelae of their disease.

Endoscopic neuroanatomy study using embalmed cadavers.

Objectives: A firm understanding of anatomy is foundational for all medical students and residents. As opportunities for cadaveric study dwindle, we propose a simplified perfusion model for formalin fixed cadavers that allow for endoscopic neuroanatomical study and procedural practice. This model is easily accessible, cost effective, and valuable in medical training. Materials and Methods: Cadavers were fixed through accepted methods that included formalin injection into the cranial vault. The perfusion system was set up using a series of catheters, tubing, and pressurized saline bag that forced saline into the various neuroanatomical spaces chosen for study. Results: A neuroendoscope was subsequently introduced to explore and identify relevant neuroanatomical structures as well as to perform a 3rd ventriculostomy and filum sectioning. Conclusion: Using formalin fixed cadavers for neuroendoscopic studies and procedural practice is a cost effective, multipurpose tool that can provide medical trainees with a strong understanding of anatomy as well as procedural practice.

Establishment of a vaccine administration training program for medical students.

While vaccine administration training is included in the curriculum for several health professions, it is not universally incorporated into the medical school preclinical curriculum. To fill this education gap, a pilot vaccine training program for first- and second-year medical students was conducted using an online Centers for Disease Control and Prevention module and an in-person simulation with nursing faculty. The aim of this study was to evaluate the effectiveness of the training program. Pre- and post-surveys used a Likert 5-point scale to assess the training effectiveness. Ninety-four students completed the surveys (response rate, 93.1%). Following the training, students felt more comfortable giving a patient a vaccine under the supervision of a physician (P < 0.0001), volunteering in a community-wide vaccine campaign (P < 0.0001), and administering vaccines during clinical rotations (P < 0.0001). Most students, 93.6%, found the in-person training to be "effective" or "very effective," and 97.8% felt that learning how to administer vaccines should be incorporated into the preclinical medical curriculum. Without this program, 76 students (80.1%) would not have been able to participate in a vaccine training. The interdisciplinary training program outlined in this study may serve as a model for similar initiatives at other medical schools.

Urban and Rural Surgical Practice Patterns for Papillary Thyroid Carcinoma.

Background: The 2015 American Thyroid Association (ATA) guidelines shifted recommendations toward less aggressive management of papillary thyroid cancer (PTC). Subsequently, several studies demonstrated a trend in performing thyroid lobectomy (TL) over total thyroidectomy (TT). However, regional variation has persisted without a clear indication of what factors may be influencing practice variation. We aimed to evaluate the surgical management of PTC in patients in rural and urban settings to assess trends of TL compared with TT following the implementation of the 2015 ATA guidelines. Methods: A retrospective cohort analysis was performed using the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2019 of patients with localized PTC <4 cm who underwent TT or TL. Patients were classified as living in urban or rural counties based on the 2013 Rural-Urban Continuum Codes. Procedures performed from 2004 to 2015 were categorized as preguidelines, while those performed from 2016 to 2019 were categorized as postguidelines. Chi-square, Student's t-test, logistic regression, and Cochran-Mantel-Haenszel test were used. Results: A total of 89,294 cases were included in the study. Eighty thousand one hundred and fifty (89.8%) were from urban settings and 9144 (9.2%) were from rural settings. Patients from rural settings were older (52 vs. 50 years, p < 0.001) and had smaller nodules (p < 0.001). On adjusted analysis, patients in rural areas were less likely to undergo TT (adjusted odds ratio 0.81, confidence interval [CI] 0.76-0.87). Before the 2015 guidelines, patients in urban settings had a 24% higher odds of undergoing TT compared with those in rural settings (odds ratio 1.24, CI 1.16-1.32, p < 0.001). There was no difference in the proportions of TT and TL based on setting following guideline implementation (p = 0.185). Conclusions: The 2015 ATA guidelines led to a change in overall practice in surgical management of PTC toward increasing TL. While urban and rural practice variation existed before 2015, both settings had an increase in TL following the guideline change, emphasizing the importance of clinical practice guidelines to ensure best practice in both rural and urban settings.

Analysis of the timing and the usage of drains following cranioplasty on outcomes and the incidence of bone resorption.

Background: Pediatric cranioplasty is associated with a high rate of complications, including bone resorption (BR) in 20-50% of cases. We aimed to evaluate factors contributing to BR, including the effect of the timing of cranioplasty and the use of post-surgical drains. Methods: This is a dual institution retrospective review of all patients under 18 years old who underwent a cranioplasty following a decompressive craniectomy (DC) for the treatment of traumatic brain injury between 2011 and 2021. Early cranioplasty was defined as within 30 days after DC and late cranioplasty as >30 days. Patients were grouped by BR and separately by timing to cranioplasty. Groups were compared based on the Glasgow Outcome Scale (GOS) and postoperative drain usage. Results: A total of 30 patients were included in the study. The mean age was 7.39 (standard deviation = 6.52) and 60% were male. The median time to cranioplasty was 13 days (interquartile range = 10-17). BR was present in 16.7% of cases. A subgaleal drain was utilized in 93.3% and an external ventricular drain (EVD) in 63.3% of patients following cranioplasty. Drain usage was not associated with BR and timing to cranioplasty was not associated with discharge or 6-month GOS. Conclusion: This study demonstrates that early cranioplasty following DC may have similar outcomes to late cranioplasty. Post-surgical EVDs and subgaleal drains did not increase the incidence of BR, suggesting their importance in the postoperative management of these patients.

Impact of timing of decompressive craniectomy on outcomes in pediatric traumatic brain injury.

Background: Decompressive craniectomy (DC) can be utilized in the management of severe traumatic brain injury (TBI). It remains unclear if timing of DC affects pediatric patient outcomes. Further, the literature is limited in the risk assessment and prevention of complications that can occur post DC. Methods: This is a retrospective review over a 10-year period across two medical centers of patients ages 1 month-18 years who underwent DC for TBI. Patients were stratified as acute (<24 h) and subacute (>24 h) based on timing to DC. Primary outcomes were Glasgow outcome scale (GOS) at discharge and 6-month follow-up as well as complication rates. Results: A total of 47 patients fit the inclusion criteria: 26 (55.3%) were male with a mean age of 7.87 ± 5.87 years. Overall, mortality was 31.9% (n = 15). When evaluating timing to DC, 36 (76.6%) patients were acute, and 11 (23.4%) were subacute. Acute DC patients presented with a lower Glasgow coma scale (5.02 ± 2.97) compared to subacute (8.45 ± 4.91) (P = 0.030). Timing of DC was not associated with GOS at discharge (P = 0.938), 3-month follow-up (P = 0.225), 6-month follow-up (P = 0.074), or complication rate (P = 0.505). The rate of posttraumatic hydrocephalus following DC for both groups was 6.4% (n = 3). Conclusion: Although patients selected for the early DC had more severe injuries at presentation, there was no difference in outcomes. The optimal timing of DC requires a multifactorial approach considered on a case-by-case basis.

Delay in Surgery and Papillary Thyroid Cancer Survival in the United States: A SEER-Medicare Analysis.

INTRODUCTION: Delays in surgery and their impact on survival in papillary thyroid cancer (PTC) is unclear. We sought to investigate the association between time to surgery and survival in patients with PTC. METHODS: A total of 8170 Medicare beneficiaries with PTC who underwent thyroidectomy were identified within the Surveillance, Epidemiology, and End Results-Medicare linked data files between 1999 and 2018. Disease-specific survival (DSS) and overall survival (OS) were estimated using Kaplan-Meir analysis, and Cox proportional hazards models were specified to estimate the association between time to surgery and survival. RESULTS: Among 8170 patients with PTC, mean age 69.3 (SD+/- 11.4), 89.8% had surgery within the first 90 days, 7.8% had surgery 91 to 180 days from diagnosis, and 2.4% had surgery after 180 days. Increasing time to surgery was associated with increased mortality for OS in the >180-day group [adjusted hazard ratio (aHR) 1.24; 95% CI, 1.01-1.53]. Moreover, on stratification by summary stage, those with localized disease in the 91- to 180-day group increased risk by 25% (aHR 1.25; 95%CI, 1.05-1.51), and delaying over 180 days increased risk by 61% (aHR 1.61; 95%CI, 1.19-2.18) in OS. Those with localized disease in the >180-day group had almost 4 times the estimated rate of DSS mortality (aHR3.51; 95%CI, 1.68-7.32). When stratified by T stage, those with T2 disease in the >180 days group had double the estimated rate of all-cause mortality (aHR 2.0; 95% CI, 1.1-3.3) and almost triple the estimated rate of disease-specific mortality (aHR 2.7; 95% CI, 1.05-6.8). CONCLUSIONS: Delays in surgery for PTC may impact OS and DSS in localized disease, prior to nodal metastasis.