Silent cerebral infarction during immune TTP remission: prevalence, predictors, and impact on cognition.

Immune thrombotic thrombocytopenic purpura (iTTP) survivors have increased risk of cardiovascular disease, including strokes, and report persistent cognitive difficulties during remission. We conducted this prospective study involving iTTP survivors during clinical remission to determine the prevalence of silent cerebral infarction (SCI), defined as magnetic resonance imaging (MRI) evidence of brain infarction without corresponding overt neurodeficits. We also tested the hypothesis that SCI is associated with cognitive impairment, assessed using the National Institutes of Health ToolBox Cognition Battery. For cognitive assessments, we used fully corrected T scores adjusted for age, sex, race, and education. Based on the diagnostic and statistical manual 5 criteria, we defined mild and major cognitive impairment as T scores with a 1 or 2 standard deviation (SD) and >2 SD below the mean on at least 1 test, respectively. Forty-two patients were enrolled, with 36 completing MRIs. SCI was present in 50% of the patients (18), of which 8 (44.4%) had prior overt stroke including during acute iTTP. Patients with SCI had higher rates of cognitive impairment (66.7% vs 27.7%; P = .026), including major cognitive impairment (50% vs 5.6%; P = .010). In separate logistic regression models, SCI was associated with any (mild or major) cognitive impairment (odds ratio [OR] 10.5 [95% confidence interval (95% CI), 1.45-76.63]; P = .020) and major cognitive impairment (OR 7.98 [95% CI, 1.11-57.27]; P = .039) after adjusting for history of stroke and Beck depression inventory scores. MRI evidence of brain infarction is common in iTTP survivors; the strong association of SCI with impaired cognition suggests that these silent infarcts are neither silent nor innocuous.

Immune thrombotic thrombocytopenic purpura: Spotlight on long-term outcomes and survivorship.

Advances in diagnosis and treatment have dramatically improved survival of acute immune thrombotic thrombocytopenic purpura (iTTP) and iTTP has evolved from an acute fatal condition to a chronic relapsing disorder. In addition to the risk of iTTP relapse, iTTP survivors are at risk of multiple adverse health outcomes including higher than expected rates of all-cause mortality, increased rates of stroke and other cardiovascular disease, and higher rates of morbidities such as obesity, hypertension, and autoimmune disorders. iTTP survivors also report neurocognitive impairment, depression, and reduced quality of life. Women with iTTP are at risk for recurrent iTTP, preeclampsia, and other maternal and fetal complications in subsequent pregnancies. ADAMTS13 activity during clinical remission has emerged as an important targetable risk factor for iTTP relapse and other outcomes including stroke and all-cause mortality. This review summarizes current literature regarding the epidemiology and potential mechanisms for adverse long-term sequelae of iTTP, outlines current best practices in iTTP survivorship care, and highlights a research agenda to improve long-term iTTP outcomes.

Standardized Medical Coding Curriculum in Surgical Graduate Medical Education.

INTRODUCTION: Despite the increasing importance of coding and billing in healthcare as a whole and calls from the Accreditation Council for Graduate Medical Education (ACGME) to emphasize systems-based practice, many surgical training programs have not prioritized coding and billing within their curricula. We aim to evaluate the performance of surgical residents and early career surgeons in coding and billing and to appraise interventions to improve coding and billing abilities within this group. METHODS: A literature search from conception to March 15th, 2022 utilizing PubMed, Google Scholar, and EMBASE was conducted to search for studies that evaluate surgical resident coding practices and interventions to improve practice management and financial competency. RESULTS: Discrepancies in coding and billing ability are prominent between residents, surgeons, and professional coders. One study demonstrated coding accuracy of 76.5% for professional coders, 62.1% for surgical attendings, and 54.1% for surgical residents, whereas another study reported a 52.82% coding accuracy and residents. Resident performance in coding and billing was inferior to their more experienced surgical attending counterparts and professional coders. Surgical residents and fellows demonstrated significantly improved knowledge and confidence in coding following the administration of either individual or longitudinal educational interventions. CONCLUSION: Coding and billing discrepancies among students, residents, and surgeons persist due to a lack of formalized training. Integration of standardized and mandated medical coding curricula and interventions within residency programs has great potential to improve surgical coding practices and should be a mandatory component of graduate medical education.

Comparing Outcomes of Appendectomy Versus Non-operative Antibiotic Therapy for Acute Appendicitis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

BACKGROUND: Acute appendicitis is one of the most common etiologies of an acute abdomen in the emergency department and first-line standard surgical care for the condition has recently been reconsidered. We aim to evaluate the effectiveness and outcomes of surgical intervention versus non-operative antibiotic therapy in the treatment of acute appendicitis in adult and pediatric patients. METHODS: A literature search was conducted using PubMed, Google Scholar, and EMBASE. The search included all studies until January 15th, 2022. Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines were followed for abstracting data and assessing data quality and validity. Data were independently extracted by the authors of the study. Meta-analysis was performed and Cohen's Q test for heterogeneous effects was performed to determine if fixed or random-effects models were appropriate for use. RESULTS: Twelve randomized controlled trials investigating a total of 3703 acute appendicitis patients met inclusion criteria and were included in the meta-analysis. In the systematic review, eleven RCTs demonstrated that appendectomy had improved effectiveness compared to non-operative antibiotic management. The meta-analysis demonstrated that patients undergoing appendectomy had significantly higher treatment effectiveness compared with antibiotics-only treatment (98.4% vs. 73.3%, P < .0001). The meta-analysis did demonstrate a significant .54-day reduction in hospital length of stay for the appendectomy group compared to the non-operative antibiotic therapy group. CONCLUSIONS: Surgical intervention is associated with increased effectiveness of treatment and reduced in-hospital length of stay among patients with acute appendicitis. Guidelines established by institutions and surgical organizations should indicate appendectomy as the standard and superior treatment option for patients presenting with acute appendicitis.

Beta-Blocker Therapy in Patients With Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

INTRODUCTION: Traumatic brain injury (TBI), a leading cause of morbidity and mortality among trauma patients worldwide, poses the risk of secondary neurological insult due to significant catecholamine surge. We aim to investigate the effectiveness and outcomes of beta-blocker administration in patients with severe TBI. METHODS: A search through PubMed, EMBASE, JAMA network, and Google Scholar databases was conducted for relevant peer-reviewed original studies published before February 15, 2022. A standard random-effects model was used, as justified by a high Cohen's Q test. RESULTS: Twelve studies met inclusion criteria and were included in the meta-analysis. Severe TBI patients who were administered beta-blockers had a significantly reduced incidence of in-hospital mortality compared to the non-beta-blocker group (14.5% vs 19.2%). However, the beta-blocker group was reported to have a significantly greater number of ventilator days (5.58 vs 2.60 days). Similarly, intensive care unit (9.00 vs 6.84 days) and hospital (17.30 vs 11.02 days) lengths of stay (LOS) were increased in the beta-blocker group compared to those who were not administered beta-blocker therapy, but only the difference in hospital-LOS was significant. CONCLUSIONS: Beta-blockers have significantly decreased in-hospital mortality in patients with severe TBI despite being associated with an increase in ventilator days and hospital-LOS. The administration of beta-blocker therapy in the management of severe TBI may be warranted and should be discussed in future guidelines.

Nationwide Analysis of Biomechanics of Motor Vehicle Collisions Involving Passenger Vehicle and Associated Outcomes: Towards Improving Vehicle Safety Standards and Regulations.

BACKGROUND: Motor vehicle collisions (MVCs) pose significant mortality and economic burden on the United States. Biomechanics research may guide future vehicle innovation. The objective of this study is to investigate the biomechanics of two-vehicle MVCs involving passenger vehicle (PV) to evaluate associated injury patterns and outcomes including mortality. METHODS: A retrospective cohort study of cases from the Crash Injury Research Engineering Network database was performed to evaluate the biomechanics (angle of impact, seatbelt use, and airbag deployment) of two-vehicle MVCs involving at least one PV from 2005-2015. RESULTS: Out of 629 MVCs evaluated, lateral collisions were most common (49.5%), followed by head-on (41.3%) and rear-end (9.2%) collisions. Thoracic injuries accounted for 30.1%, 31.4%, and 31.1% of injuries in lateral, head-on, and rear-end collisions, respectively, and were the most common body region injured for all collision types. Seatbelt use was associated with shorter ICU stay (10.9 vs 19.1 days, P = .036) and mortality (Cramer's V = .224, P < .001), but a greater average number of injuries (10.2 injuries vs 8.6 injuries, P = .011). CONCLUSION: Passenger vehicle are commonly involved in MVCs nationwide and efforts are needed to prevent occupant injuries and fatalities. The incorporation of energy-absorbing material into common points of contact within the vehicle interior may decrease the severity of these injuries. Seatbelt use remains a protective factor against MVC-fatalities but is associated with collateral injuries and should be a focus of further innovation.

Shifting the Surgical Residency Match to a 100% Virtual Interview Format During the COVID-19 Pandemic, How has It Affected Placement Into Surgical Training Programs?

INTRODUCTION: The AAMC transitioned to virtual interview formats for the 2020-2021 residency match. This study aims to examine the impact of the 100% virtual interview format for the 2020-2021 residency match on both application and match changes for multiple surgical specialties, including neurosurgery (NS), orthopedic surgery (OS), plastic surgery (PS), general surgery (GS), thoracic surgery (TS), and vascular surgery (VS). METHODS: Cross-sectional study comparing application and match changes between the in-person 2019-2020 and virtual 2020-2021 residency match cycles for different surgical specialties. RESULTS: There was an overall increase in the number of applicants for 5 of the surgery specialties but not VS, and an overall increase in the number of applications per residency program across all specialties. The average number of applications per applicant also increased, except in TS. There were no major match changes except in TS, which saw an increase in number of spots filled by MDs to nearly 100% from 84.2% in the previous cycle. CONCLUSION: The switch to the 100% virtual 2020-2021 residency match interview format was associated with an overall increase in the number of applications per program and number of applications per applicant across multiple surgical specialties. There was a decrease in the number of applicants to VS and an increase in the number of applications per applicant. The switch to a virtual interview format in 2020-2021 was also associated with an increase in TS spots filled by MDs to almost 98%, increasing the already concerning TS match disparity for DO and IMG applicants.

Analysis of Biomechanics of Motor Vehicle Collisions for Passenger Cars: Implications for Passenger Vehicle Safety and Future Car Design Innovations.

INTRODUCTION: Investigating biomechanics of injury patterns from motor vehicle collisions (MVCs) informs improvements in vehicle safety. This study aims to investigate two-vehicle MVCs involving a passenger car and specific injury patterns associated with sources of injury, collision biomechanics, vehicle properties, and patient outcomes. METHODS: Retrospective cohort study conducted to evaluate the biomechanics of specific injury patterns seen in MVCs involving passenger cars using the Crash Injury Research Engineering Network database between the years 2005 and 2015. RESULTS: A total of 631 MVC cases were included from 2005 to 2015. The majority of cases involved injuries to the head or neck, the thorax, and the abdomen (80.5%). Head/neck injuries from the steering wheel were associated with significantly higher injury severity score compared to those from seatbelts (26.11 versus 18.28, P < 0.001) and airbags (26.11 versus 20.10, P = 0.006), as well as a >6-fold higher fatality rate (P = 0.019). Thoracic injuries caused by the center console were twice as likely to be fatal than those caused by the seatbelt (P = 0.09). CONCLUSIONS: Occupants suffering injuries to the head/neck, the thorax, and the abdomen had higher injury severity score and fatality rates compared to other body regions, demonstrating that manufacturing and safety guidelines should focus on minimizing these injury patterns. Head/neck injuries caused by the steering wheel were associated with worse outcomes compared to those caused by seatbelts and airbags, further emphasizing the benefits of these critical safety features. Integration of innovative safety features like center-mounted airbags may improve occupant safety.

Gender Distribution & Rank of Authorship in Surgical Literature.

BACKGROUND: Authorship of surgical literature is important for the career advancement of surgeons, and gender disparities in authorship may hinder the representation and leadership of women within academic surgery. The aim of this systematic review and meta-analysis was to evaluate the gender distribution of first, senior, and overall authorship in peer-reviewed surgical journal studies across all surgical specialties to determine if disparities exist. METHODS: PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the gender distribution of authorship of surgical literature published before December 10th, 2021. Meta-analysis was performed and Cohen's Q test for heterogenous effects was used to determine whether random or fixed-effects models were appropriate. RESULTS: Fifteen studies investigating gender distribution of authorship met inclusion, which included a total of 136,627 pooled studies. The meta-analysis demonstrated the meta-proportion of first authorship for women to be 20.6% (95% CI: 13.9, 28.2), the meta-proportion of senior authorship for women to be 11.9% (95% CI: 6.6, 18.5), and the meta-proportion of overall authorship for women to be 23% (95% CI: 16.2, 30.7). In addition, the proportion of senior authorship for women was found to be significantly lower than the proportion of overall authorship for women (11.9% versus 23.0%, P = .0106). CONCLUSION: There is a significantly smaller proportion of women who are first, senior, and overall authors in surgical literature compared to their colleagues who are men. Sustainable and effective solutions aimed at improving the representation of women surgeons in surgical research and research leadership are necessary.

Nationwide analysis of proximity of American College of Surgeons-verified and state-designated trauma centers to the nearest highway exit and associated prehospital motor vehicle collision fatalities.

BACKGROUND: Motor vehicle collisions remain a leading cause of trauma-related deaths. We aim to investigate the relationship between the proximity of trauma centers to the nearest highway exit and prehospital motor vehicle collision fatalities at the county level nationwide. METHODS: This was a cross-sectional study evaluating the association between the distance of trauma centers to the nearest highway exit and prehospital motor vehicle collision fatalities between the years 2014 and 2019. Prehospital motor vehicle collision fatalities were obtained from National Highway Traffic Safety Administration. Mapping software was used to determine the distance of trauma center to the nearest highway exit and transport time. Linear regression analysis was performed. RESULTS: A total of 2,019 American College of Surgeons-verified and/or state-designated trauma centers were included (211 Level 1, 356 Level 2, 491 Level 3, and 961 Level 4 trauma centers). Prehospital motor vehicle collision fatalities were positively correlated with the distance of trauma center to the nearest highway exit for counties with trauma centers located ≤5 miles from the nearest highway exit (r = 0.328; P < .001). In the 612 counties with a 10% increase in prehospital motor vehicle collision fatalities from 2014 to 2019, prehospital motor vehicle collision fatalities were also positively correlated with distance to the nearest highway exit (r = 0.302; P < .001). The counties with more dispersed distributions of trauma centers were significantly associated with motor vehicle collision fatalities (Spearman's rank coefficient = 0.456; 95% confidence interval, 0.163-0.675; P = .003). CONCLUSION: Shorter distances between trauma centers and the nearest highway exit are associated with fewer prehospital motor vehicle collision fatalities for counties with trauma centers ≤5 miles of the nearest highway exit. Further enhancement of existing highway infrastructure and standardization of emergency medical services transport protocols are needed to address the burden of prehospital motor vehicle collision fatalities in the United States.

Timing of tracheostomy in patients with severe traumatic brain injuries: The need for tailored practice management guidelines.

INTRODUCTION: Traumatic brain injury (TBI) is one of the leading causes of fatal trauma, and patients often require prolonged ventilation and tracheostomy. There are currently no standardized guidelines regarding the optimal timing of tracheostomy placement for mechanically ventilated patients with severe TBI. This review aims to investigate the impact of tracheostomy timing on the clinical outcomes in patients with severe TBI. METHODS: A literature search was conducted according to PRISMA 2020 guidelines. PubMed, Google Scholar, EMBASE, MedLine, Web of Science, Cochrane, and CINAHL were searched for studies evaluating the impact of early versus late tracheostomy on TBI patient outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Newcastle-Ottawa Scale (NOS) were used for quality of evidence and risk of bias assessment, respectively. RESULTS: A total of nine studies met eligibility criteria. All nine studies investigated tracheostomy timing in severe TBI patients and demonstrated that early tracheostomy is associated with decreased ICU length-of-stay (LOS) and increased ventilator free-days compared to late tracheostomy. CONCLUSION: Current evidence suggests that patients with severe TBI following traumatic injury may benefit from an early tracheostomy due to improved clinical outcomes, including decreased MV duration and ICU-LOS, compared to late tracheostomy. Further multi-institutional studies are needed to develop evidence-based guidelines.

Preoperative and Postoperative Cognitive Assessment in Geriatric Patients Following Acute Traumatic Injuries: Towards Improving Geriatric Trauma Outcomes.

INTRODUCTION: A growing percentage of the US population is over the age of 65, and geriatrics account for a large portion of trauma admissions, expected to reach nearly 40% by 2050. Cognitive status is important for operative management, especially in elderly populations. This study aims to investigate preoperative and postoperative cognitive function assessment tools in geriatric patients following acute trauma and associated outcomes, including functional status, postdischarge disposition, mortality, and hospital length of stay (H-LOS). METHODS: A literature search was conducted using Medline/PubMed, Google Scholar, Embase, JAMA Networks, and Cochrane databases for studies investigating the use of cognitive assessment tools for geriatric patients with acute trauma. The last literature search was conducted on November 13, 2021. RESULTS: Ten studies were included in this review, of which five focused on preoperative cognitive assessment and five focused on postoperative. The evidence suggests patients with preoperative cognitive impairment had worse functional status, mortality, and postdischarge disposition along with increased LOS. Acute trauma patients with postoperative cognitive impairment also had worse functional status, mortality, and adverse postdischarge disposition. CONCLUSIONS: Preoperative and postoperative cognitive impairment is common in geriatric patients with acute trauma and is associated with worse outcomes, including decreased functional status, increased LOS, and adverse discharge disposition. Cognitive assessment tools such as MMSE, MoCA, and CAM are fast and effective at detecting cognitive impairment in the acute trauma setting and allow clinicians to address preoperative or postoperative cognitive impairments to improve patient outcomes.

The Role of Pericardial Window Techniques in the Management of Penetrating Cardiac Injuries in the Hemodynamically Stable Patient: Where Does It Fit in the Current Trauma Algorithm?

INTRODUCTION: Penetrating cardiac injuries (PCIs) have high in-hospital mortality rates. Guidelines regarding the use of pericardial window (PW) for diagnosis and treatment of suspected PCIs are not universally established. The objective of this review was to provide a critical appraisal of the current literature to determine the effectiveness and safety of PW as both a diagnostic and therapeutic technique for suspected PCIs in patients with hemodynamic stability. METHODS: A review was conducted using PubMed/MEDLINE, Google Scholar, and Embase to identify literature evaluating the accuracy and therapeutic efficacy of PW and its role in a hemodynamically stable patient with penetrating thoracic or thoracoabdominal trauma. RESULTS: Eleven studies evaluating diagnostic PW and two studies evaluating therapeutic PW were included. These studies ranged from (y) 1977 to 2018. Existing literature indicates that PW is highly sensitive (92%-100%) and specific (96%-100%) for the diagnosis of suspected PCIs. PW and drainage, when compared with sternotomy, may be associated with decreased total hospital stay (4.1 versus 6.5 d; P < 0.001) and intensive care unit stay (0.25 versus 2.04 d; P < 0.001) along with similar mortality and complication rates after the management of hemopericardium. CONCLUSIONS: In a hemodynamically stable patient presenting with penetrating cardiac trauma with a high suspicion for PCI, PWs can (1) facilitate prompt diagnosis in the event of equivocal ultrasonography findings and (2) serve as an effective therapeutic modality with the benefit of potentially avoiding more invasive procedures. Subxiphoid, transdiaphragmatic, and laparoscopic approaches for PW have been shown to have similar efficacy and safety.

Twelve-step Approach for Academic Development Planning in Academic Surgery: Climbing the Academic Uphill With Strong and Steady Steps.

MINI-ABSTRACT: Surgical trainees and young academic surgeons should understand the specifics of the career they are pursing, and surgeon mentors should enhance their leadership roles and support the recruitment and retainment of academic surgeons through effective academic career support and strategic planning. Utilizing academic development planning can serve as an essential tool as both mentors & mentees navigate different career choices towards achieving a successful and sustainable academic career advancement.

Getting under the skin: Social isolation and biological markers in the National Health and Aging Trends Study.

BACKGROUND: Social isolation is a risk factor for morbidity and mortality comparable to well-established risk factors including smoking, hypertension, and a sedentary lifestyle. The specific biological mechanisms that connect social isolation to morbidity and mortality remain unclear. Interleukin-6 (IL-6) and C-reactive protein (CRP) are biological markers that are upregulated during inflammation and can have long-term negative consequences for the health of individuals as they age. METHODS: Utilizing Round 7 (2017) data from the National Health and Aging Trends Study (NHATS), we examine the relationship between social isolation and two biological markers: IL-6 and high-sensitivity CRP. This study included a nationally representative sample of 4648 Medicare beneficiaries 65 years and older who provided samples using dried blood spot (DBS) techniques. We defined social isolation utilizing a multi-domained typology that considers living arrangement, core discussion network, religious attendance, and social participation. IL-6 and CRP were obtained via DBS that were collected in Round 7 of the NHATS. We performed linear regression to examine the association between social isolation and biological markers IL-6 and CRP. RESULTS: After adjusting for age, gender, race/ethnicity, income, tobacco use, body mass index, and chronic conditions, we found that severe social isolation and social isolation were significantly associated with higher levels of IL-6 and CRP values among older adults. CONCLUSIONS: Social isolation is associated with higher levels of biological markers (IL-6 and CRP). Our findings inform the pathway between social isolation and morbidity and mortality among older adults. IL-6 or CRP could be a proximal outcome measures for future clinical and social interventions that seek to alter the trajectory of social isolation and its associated health outcomes.

Major adverse cardiovascular events in survivors of immune-mediated thrombotic thrombocytopenic purpura.

Cardiovascular disease is a leading cause of death in survivors of immune-mediated thrombotic thrombocytopenic purpura (iTTP), but the epidemiology of major adverse cardiovascular events (MACE) in iTTP survivors is unknown. We evaluated the prevalence and risk factors for MACE, defined as the composite of non-fatal or fatal myocardial infarction (MI), stroke, and cardiac revascularization, during clinical remission in two large iTTP cohorts (Johns Hopkins University and Ohio State University). Of 181 patients followed for ≥ 3 months after recovery from acute iTTP, 28.6% had a MACE event over a median follow up of 7.6 years. Stroke was the most common type of MACE (18.2%), followed by non-fatal MI (6.6%), cardiac revascularization (4.9%) and fatal MI (0.6%). Compared to the general United States population, iTTP survivors were younger at first stroke in remission (males [56.5 years vs. 68.6 years, p = 0.031], females [49.7 years vs. 72.9 years, p < 0.001]) or MI in remission (males [56.5 years vs. 65.6 years, p < 0.001] and females [53.1 years vs. 72.0 years, p < 0.001]). Age (HR 1.03 [95% CI 1.002-1.054]), race (Black/Other vs. White) (HR 2.32 [95% CI 1.12-4.82]), and diabetes mellitus (HR 2.37 [95% CI 1.09-0.03]) were associated with MACE in a Cox regression model also adjusted for sex, hypertension, obesity, hyperlipidemia, chronic kidney disease, atrial fibrillation, autoimmune disease, and relapsing iTTP. Remission ADAMTS13 activity was not significantly associated with MACE. In conclusion, iTTP survivors experience high rates of MACE and may benefit from aggressively screening for and managing cardiovascular risk factors.

Engage me: Will residency program directors listen?

•The implementation of multi-level modifications, including but not limited to outreach initiatives and the development of a holistic application review approach, are potential strategies to improve diversity and inclusivity in general surgery residency recruitment.•We encourage program directors to invest in trainees' success and implement human capital changes that produce sustinable and effective changes, and help in building the pipeline.•Program directors are encouraged to work with their institutions to develop a holistic review approach through the following initiatives: recruitment of an inclusive and diverse interview selection committee, implementation of implicit bias training among all faculty and residents participating in the selection process, and promotion of structured interviews that focus on applicant characteristics that resonate with the program's mission statement.