Is the Hartmann's procedure for diverticulitis obsolete? National trends in colectomy for diverticulitis in the emergency setting from 1993 to 2018.

BACKGROUND: Historically, Hartmann's procedure (HP) has been the operation of choice for diverticulitis in the emergency setting. However, recent evidence has demonstrated the safety of primary anastomosis (PA) with or without diverting ileostomy. The purpose of this study was to evaluate the trends of, and factors associated with, HP compared to PA in emergency surgery for diverticulitis over 25 years. METHODS: Using the National Inpatient Sample database, we identified adult patients ≥ 18 years old who underwent emergency surgery for diverticulitis (HP or PA) between 1993 and 2018 using ICD-9 and ICD-10 codes. Patients with inflammatory bowel disease, gastrointestinal cancer or who underwent elective diverticulitis surgery were excluded. Trends in HP were analyzed using multivariable linear regression, and factors associated with HP were assessed with multiple logistic regression. RESULTS: Of 499,433 patients who underwent colectomy in the emergency setting for acute diverticulitis, 271,288 (54.3%) had a HP and 228,145 (45.7%) had a PA. Median age was 61 years (IQR: 50-73), 53% were women, and 70.5% were white. The proportion of HP slightly increased over the study period-HP comprised 52.6% of included cases in 1993-98 and 55.2% of cases in 2014-2018 (p = 0.017). Advanced age (reference = 18-44 years; 45-54 years: OR 1.16, 95% CI 1.10-1.22; 55-64 years: OR 1.26, 95% CI 1.20-1.33; 65-74 years: OR 1.33, 95% CI 1.25-1.42; ≥ 75 years: OR 1.51, 95% CI 1.41-1.62), complicated diverticulitis (OR 1.41, 95% CI 1.36-1.46), and severity of illness (reference = minor; moderate: OR 1.46, 95% CI 1.38-1.54; major/extreme: OR 3.43, 95% CI 3.25-3.63) were associated with increased odds of HP. CONCLUSIONS: Over a 26-year period, HP has remained the most performed procedure in the emergency setting for diverticulitis. Future work should focus on knowledge translation with a possible change in practice as more randomized controlled trials provide support for PA.

Incidence of and risk factors associated with care fragmentation following bariatric surgery.

BACKGROUND: Current readmission rates do not account for readmissions to nonindex hospitals and may underestimate the actual burden of readmissions. OBJECTIVE: Using a nationally representative database, we sought to characterize nonindex readmissions following bariatric surgery and identify risk factors associated with readmission to a nonindex hospital. SETTING: Patients in the United States undergoing elective bariatric surgery. METHODS: The Nationwide Readmissions Database was used to identify a weighted sample of 545,377 patients undergoing elective bariatric surgery between 2010 and 2014. Multivariable logistic regression analysis was used to identify factors associated with readmission to a nonindex hospital. RESULTS: Among all patients, 5.6% were readmitted at least once within 30 days. Within the subgroup of patients who were readmitted, 17.6% were readmitted to a different hospital than the index admission hospital. Factors independently associated with higher odds of readmission to a nonindex hospital were primary payor (Medicare: odds ratio [OR] = 1.48, 95% confidence interval [CI]: 1.24-1.75; Medicaid: OR = 1.56, 95% CI: 1.26-1.95), All Patients Refined Diagnosis Related Group severity of illness score (extreme versus minor: OR = 1.48; 95% CI: 1.04-2.09), primary procedure (laparoscopic sleeve gastrectomy versus laparoscopic gastric bypass: OR = 1.23; 95% CI: 1.05-1.44), hospital bed size (reference: small hospital, medium: OR = .52, 95% CI: .39-.70; large: OR = .47, 95% CI: .35-.63), hospital ownership (reference: private, nonprofit hospital, government: OR = 1.77, 95% CI: 1.32-2.37; private, investor-owned: OR = 1.33, 95% CI: 1.07-1.64), and hospital location (reference: metropolitan area >1 million population, metropolitan <1 million population: OR = .44, 95% CI: .34-.56; micropolitan/rural: OR = .44, 95% CI: .27-.73). CONCLUSION: Failure to account for readmissions to different hospitals may underestimate readmission rates by approximately 18%.

Injuries following motorcycle crashes at a level-1 trauma center in Riyadh.

BACKGROUND: Motor vehicle crashes are the third leading cause of death in Saudi Arabia. Motorcycle riders, in particular, are considered more vulnerable than occupants, yet there are no previous studies that have examined the epidemiology of their injuries and outcomes in the country. Better understanding is needed to inform policymakers and guide future prevention programs. OBJECTIVE: Describe patterns of injury among conscious and unconscious patients injured in motorcycle crashes. DESIGN: Retrospective chart review. SETTINGS: Level 1 trauma center in Riyadh. PATIENTS AND METHODS: This retrospective study included all patients involved in motorcycle crashes who were admitted between 2001 and 2017. Medical records were reviewed, and data about injury characteristics, outcomes and healthcare utilization were ascertained. MAIN OUTCOME MEASURES: Injury site and mortality rate. SAMPLE SIZE AND CHARACTERISTICS: 572 patients included 488 males (85.3%) and 232 <18 years of age (40.5%), mean (SD) age 21.1 (11.6) years. RESULTS: About 3% of patients died either before or after admission. Extremity injuries (356, 62.2%) were most common followed by head injuries (229, 40%). Fifty-six (9%) suffered amputation, mostly to a lower limb. CONCLUSION: This study underscores the significant burden of motorcycle-related injuries on population health of Saudi Arabia. The number of amputations due to motorcycle injuries is striking. Therefore, we need to increase enforcement of safety measures during recreational use of motorcycles and to raise awareness about the dangers of motorcycle crashes to improve traffic safety and ultimately population health. LIMITATIONS: The study was conducted at a single hospital which may affect the generalizability of the data to the Saudi population. CONFLICT OF INTEREST: None.

Prevalence and predictors of postoperative thiamine deficiency after vertical sleeve gastrectomy.

BACKGROUND: As the vertical sleeve gastrectomy (VSG) becomes increasingly popular, its effect on postoperative micronutrient levels, such as thiamine, becomes more important. We previously found a 1.8% prevalence of thiamine deficiency in bariatric patients before surgery. OBJECTIVE: The aims of this study were to determine the prevalence of thiamine deficiency at our center after VSG and to explore possible predictors of postoperative thiamine levels. SETTING: University hospital, United States. METHODS: A retrospective chart review was performed on 147 bariatric patients between 18- and 65-years old who underwent VSG between April 2011 and February 2015. Demographic characteristics, preoperative body mass index (BMI), obesity-associated co-morbidities, alcohol intake, smoking habits, insurance type, calendar year of the procedure, occurrence of postoperative complications, and compliance with postoperative nutrition and follow-up appointment guidelines were extracted from clinical charts. We defined thiamine deficiency as<78 nM on any lab draw within 1 year after the VSG. The χ2, Fisher exact, and Mann-Whitney U tests, and multivariate logistic regression models were created to analyze the association of the above factors with thiamine deficiency after a VSG. RESULTS: Of 147 patients, 105 met inclusion criteria and were analyzed, of whom 27 (25.7%) had thiamine deficiency. Overall median age was 42 years (interquartile ratio: 36, 49). The majority of patients were either African Americans or Caucasian (47.6% and 44.8%, respectively), female (77.1%), and compliant with vitamins (81.0%). The overall mean preoperative BMI was 46.4 kg/m2. Patients with thiamine deficiency were more likely to be African American (66.7%, P = .024), have a larger preoperative BMI (P = .026), and to report repetitive episodes of nausea (59.3%, P = .002) and vomiting (44.4%, P = .001) at any of their postoperative appointments within 1 year after surgery. Compliance with vitamins did not differ between those with or without thiamine deficiency (70.4%, 84.6%, P = .10). After controlling for all factors, African American race (odds ratio [OR] 3.9, P = .019), higher preoperative BMI (OR 1.13, P = .001), nausea (OR 3.81, P = .02), and vomiting (OR 3.49, P = .032) were independent risk factors for the development of thiamine deficiency. CONCLUSIONS: We found an alarmingly high prevalence of thiamine deficiency in postoperative SG patients. This disorder may have serious consequences including Wernicke encephalopathy; hence, it is important to identify predictive demographic, postoperative, and behavioral factors so that appropriate measures can be taken to prevent thiamine deficiency in VSG patients.

Outcomes of common general surgery procedures for patients discharged over weekends at a tertiary care hospital in Saudi Arabia.

BACKGROUND: Hospitals usually reduce staffing levels and services over weekends. This raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk of adverse events post-discharge. OBJECTIVES: To assess the outcomes of common general surgery procedures for patients discharged over weekends, and to identify the key predictors of early readmission. DESIGN: Retrospective cohort study. SETTING: A tertiary care center. PATIENTS AND METHODS: Patients discharged from general surgery services during the one-year period between January and December 2016 after cholecystectomy, appendectomy, or hernia repairs were included. Patient demographic information, comorbidities, and complications as well as admission and follow-up details were collected from electronic medical records. MAIN OUTCOME MEASURES: Outcomes following weekend discharge, and the predictors of early readmission. SAMPLE SIZE: 743 patients. RESULTS: The operations performed: 361 patients (48.6%) underwent a cholecystectomy, 288 (38.8%) an appendectomy, and 94 (12.6%) hernia repairs. A significantly lower number of patients were discharged over the weekend (n=125) compared to those discharged on weekdays (n=618). Patients discharged during the weekend were younger, less likely to have chronic diseases, and had a significantly shorter average length of stay (LOS) (median 2 days, IQR: 1, 4 vs. median 3 days, IQR: 1, 5, P=.002). Overall, the 30-day readmission rate was 3.2% (n=24), and weekend discharge (OR=2.25, 95% CI 0.52-9.70) or any other variable did not predict readmission in 30 days. However, 14-day post-discharge follow-up visits were significantly lower in the weekend discharge subgroup (83.1% vs. 91.2%, P=.006). CONCLUSION: Weekend discharge was not associated with higher readmission rates. Physicians may consider discharging post-operative patients over a weekend without an increased risk to the patient. Day of discharge, length of stay and increased patient age are not predictors of early readmission. LIMITATIONS: Single-center study and retrospective. CONFLICT OF INTEREST: None.

Conscious status is associated with the likelihood of trauma centre care and mortality in patients with moderate-to-severe traumatic brain injury.

OBJECTIVE: To assess the relationship between The International Classification of Diseases, Ninth Revision, Clinical Modification-derived conscious status and mortality rates in trauma centres (TC) vs. non-trauma centres (NTC). METHODS: Patients in the 2006-2011 Nationwide Emergency Department Sample meeting, The Centers for Disease Control and Prevention criteria for traumatic brain injury (TBI), with head/neck Abbreviated Injury Scale (AIS) scores ≥3 were included. Loss of consciousness (LOC) was computed for each patient. Primary outcomes included treatment at a level I/II TC vs. NTC and in-hospital mortality. We compared logistic regression models controlling for patient demographics, injury characteristics, and AIS score with identical models that also included LOC. RESULTS: Of 66,636 patients with isolated TBI identified, 15,761 (23.6%) had missing LOC status. Among the remaining 50,875 patients, 59.0% were male, 54.0% were ≥65 years old, 56.7% were treated in TCs, and 27.3% had extended LOC. Patients with extended LOC were more likely to be treated in TCs vs. those with no/brief LOC (71.1% vs. 51.4%, p < 0.001). Among patients aged <65, TC treatment was associated with increased odds of mortality [Adjusted Odds Ratio (AOR) 1.79]; accounting for LOC substantially mitigated this relationship [AOR 1.27]. Similar findings were observed among older patients, with reduced effect size. CONCLUSION: Extended LOC was associated with TC treatment and mortality. Accounting for patient LOC reduced the differential odds of mortality comparing TCs vs. NTCs by 60%. Research assessing TBI outcomes using administrative data should include measures of consciousness.

The Epidemiology of Pediatric Head Injury Treated Outside of Hospital Emergency Departments.

BACKGROUND: Although head trauma-related deaths, hospitalizations, and emergency department visits are well characterized, few studies describe pediatric patients presenting outside of emergency departments. We compared the epidemiology and extent of healthcare-seeking pediatric (0-17 years) patients presenting in outpatient settings with those of patients seeking nonhospitalized emergency department care. METHODS: We used MarketScan Medicaid and commercial claims, 2004-2013, to identify patients managed in two outpatient settings (physician's offices/clinics, urgent care) and the emergency department. We then examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention-defined head trauma diagnoses, the extent of and reasons for post-index visit ambulatory care use within 30/90/180 days, and annual and monthly variations in head trauma trends. Outpatient incidence rates in 2013 provided estimates of the nationwide US outpatient burden. RESULTS: A total of 1,683,097 index visits were included, representing a nationwide burden in 2013 of 844,660 outpatient cases, a number that encompassed 51% of healthcare-seeking head trauma that year and that substantially increased in magnitude from 2004 to 2013. Two-thirds (68%) were managed in outpatient settings. While demographic distributions varied with index-visit location, injury-specific factors were comparable. Seasonal spikes appeared to coincide with school sports. CONCLUSIONS: There is an urgent need to better understand the natural history of head trauma in the >800,000 pediatric patients presenting each year for outpatient care. These outpatient injuries, which are more than double the number of head trauma cases recorded in the hospital-affiliated settings, illustrate the potential importance of expanding inclusion criteria in surveillance and prevention efforts designed to address this critical issue.

Conscious status predicts mortality among patients with isolated traumatic brain injury in administrative data.

BACKGROUND: Outcome studies in trauma using administrative data traditionally employ anatomy-based definitions of injury severity; however, physiologic factors, including consciousness, may correlate with outcomes. We examined whether accounting for conscious status in administrative data improved mortality prediction among patients with moderate to severe TBI. METHODS: Patients meeting Centers for Disease Control and Prevention (CDC) guidelines for TBI in the 2006 to 2011 Nationwide Emergency Department Sample were identified. Patients were dichotomized as having no/brief loss of consciousness (LOC) vs extended LOC greater than 1 hour using International Classification of Diseases, Ninth Revision (ICD-9) fifth digit modifiers. Receiver operating curves compared the ability of logistic regression to predict mortality in models that included LOC vs models that did not. RESULTS: Overall, 98,397 individuals met criteria, of whom 25.8% had extended LOC. In univariate analysis, AIS alone predicted mortality in 69.6% of patients (area under receiver operating characteristic curve .696, 95% CI .689 to .702), extended LOC alone predicted mortality in 76.8% (AUROC .768, 95% CI .764 to .773), and a combination of AIS and extended LOC predicted mortality in 82.6% of cases (AUROC .826, 95% CI .821 to .830). Similar differences were observed in best-fit models. CONCLUSIONS: Accounting for LOC along with anatomical measures of injury severity improves mortality prediction among patients with moderate/severe TBI in administrative datasets. Further work is warranted to determine whether other physiological measures may also improve prediction across a variety of injury types.