Cecal volvulus secondary to mesodiverticular band.

Meckel's diverticula are one of the most common gastrointestinal anomalies, yet mesodiverticular bands are rare. The treatment of these bands commonly requires surgery. A healthy patient in his 20s presented to the emergency department with a 1 day history of acute onset abdominal pain. Computed tomography imaging was consistent with volvulus of the large intestine. In the operating room, the patient was noted to have a band between the ileal mesentery and tip of a Meckel's diverticulum, consistent with a mesodivertiular band, through which cecum had volvulized. The patient underwent resection. The patient recovered without major complications. Mesodiverticular bands are rare, but may present as hemoperitoneum, small bowel obstruction, or volvulus. Pre-operative diagnosis of a mesodiverticular band is often difficult and they are most commonly diagnosed intraoperatively. Treatment should include surgery and may include simple lysis of the band, bowel resection, or more extensive resection if other pathology is present.

Bone Anchor Fixation in the Repair of Blunt Traumatic Abdominal Wall Hernias: A Western Trauma Association Multicenter Study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair. METHODS: A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses. RESULTS: 176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts. CONCLUSIONS: This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

The Effect of Body Mass Index on the Creation of an End-Colostomy in Rectal Cancer Patients.

With the increasing prevalence of obesity, there has been a parallel increase in the incidence of rectal cancer. The association of body mass index (BMI) and end-colostomy creation versus primary anastomosis in patients undergoing proctectomy for rectal cancer has not been described. This is a retrospective study of patients with rectal cancer from 2012 to 2018 using data from the National Surgical Quality Improvement Project. 16,446 (92.1%) underwent primary anastomosis and 1,418 (7.9%) underwent creation of an end-colostomy. Patients with a BMI of 25-29.9 (overweight) comprised the most frequent group to have a proctectomy (reference group), but the least likely to have an end-colostomy. Patients with severe obesity (BMI 50+) had an adjusted odds ratio for end-colostomy of 2.7 (95% CI 1.5-4.7) compared to the reference group. Patients who have severe obesity should be counseled regarding the likelihood of an end-colostomy and may benefit from medical weight management or weight-loss surgery.

Quality of life, quality of business, and destinations of recent graduates: fields of study matter.

One of the main challenges facing non-metropolitan regions is the attraction and retention of highly-educated young people. A loss of the brightest can lead to reduced business creation, innovation, growth and community well-being in such regions. We use rich longitudinal microdata from New Zealand to analyse the determinants and geography of the choice of destination of recent university and polytechnic graduates 2 years and 4 years after graduation. Rather than considering a range of location-specific consumption and production amenities, we assume spatial equilibrium and calculate, following Chen and Rosenthal (J Urban Econ 64:519-537, 2008), 'quality of life' and 'quality of business' indicators for urban areas that encompass all amenities that are utility and/or productivity enhancing (or reducing, in the case of disamenities). Specifically, we test whether students locate in places that are regarded as good to live or good to do business; and how this differs by field of study. Our estimates are conditional on students' prior school (home) location and the location of their higher education institution. We find that graduates are attracted to locate in urban places that have high quality production amenities. High quality consumption amenities have heterogeneous effects on the location choice of students. Creative arts and commerce graduates are relatively more likely to locate in places that are attractive to business, consistent with a symbiosis between bohemians and business. Decision makers can leverage their existing local strengths, in terms of production and/or consumption amenities, to act as drawcards for, or to retain, recent graduates in specific fields.

Migration of dual-earner couples: a subjective wellbeing approach.

We model push factors that determine the domestic migration decisions for couples, with emphasis on dual-earner different-sex couples. Unlike many prior studies that concentrate on labour market determinants of migration, we place the subjective well-being (SWB) reported by each partner at centre stage. We test whether migration determinants differ depending on whether the female is the main breadwinner in a dual-earner couple. We also test if determinants differ when either the female or the male is the sole earner within a couple. The evidence shows that a couple is more likely to migrate if she reports low SWB in the year prior to migration, with the strength of this effect varying depending on the earnings status of each partner prior to migration. Male SWB does not have the same impact on the migration choice although we find some evidence that pre-migration male wages impact the migration decision.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study.

BACKGROUND: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Measuring Pandemic and Lockdown Impacts on Wellbeing.

With the onset of the COVID-19 pandemic, New Zealand's official statistical agency (Stats NZ) moved quickly to supplement the quarterly Household Labour Force Survey with wellbeing measures from the General Social Survey. The first supplement (June 2020) began toward the end of a restrictive national lockdown. Subsequent quarterly surveys continued through a second lockdown for the Auckland region, enabling tests of regional lockdown impacts. Survey measures include questions on life satisfaction, health, income adequacy, social capital (trust), and loneliness. Published aggregated data indicate that life satisfaction, social capital, health, and financial wellbeing were each higher through the pandemic (in 2020) than prior to it, including for disadvantaged groups, but loneliness rose. Analysis of the individual-level data, confined to the within-pandemic period, however indicates that more restrictive lockdowns were associated both with reduced life satisfaction and greater loneliness, with differing impacts according to labor market and household status.

Land loss and the intergenerational transmission of wellbeing: The experience of iwi in Aotearoa New Zealand.

We analyse the impact of land loss, through colonisation, on contemporary cultural wellbeing and health outcomes of Maori, the Indigenous population of Aotearoa New Zealand. In 1840, Maori legally owned all land in the country; by 2017, Maori owned just 5% of land. Ties to the land (whenua) have been identified as being critical to spirituality (wairua) and health (hauora). All tribes (iwi) experienced major land loss, but the timing, extent and nature of land loss differed across iwi. In some cases, land was confiscated following the New Zealand wars of the nineteenth century. We draw on recently derived data for historical landholdings of 70 (North Island) iwi to link the extent of historical landholdings, and whether land was confiscated, to contemporary outcomes for five cultural wellbeing and health outcomes for each iwi: te reo Maori (Maori language) proficiency, importance of involvement in Maori culture, visiting an ancestral marae (meeting place), difficulty in finding support for Maori cultural practices, and rates of regular smoking. We find that higher land retention within an iwi's rohe at the end of the nineteenth century is supportive of contemporary cultural wellbeing outcomes, while confiscation is linked to higher contemporary rates of smoking. The evidence is consistent with historical trauma having significant effects on the cultural wellbeing and health outcomes of Aotearoa New Zealand's Indigenous population over a century later.

What Matters for the Wellbeing of Mothers and Children in Material Hardship? Application of a Modified Indicator Framework.

We examine determinants of subjective wellbeing (SWB) for mothers of dependent children in material hardship, using a modification of the New Zealand Treasury's Living Standards Framework (LSF) and data from the General Social Survey. We convert the LSF-an indicator dashboard-into a tool for prioritising social policies by placing SWB at the head of a hierarchy of wellbeing domains. Several determinants of these mothers' SWB conform to standard findings; however, two important differences stand out. One is the lack of a protective effect from employment on SWB for this group (unlike the protective effect for males). The other is a positive relationship between a mother's SWB and satisfaction with her own skills/knowledge; this effect is particularly strong for sole mothers in hardship, dominating any effect of qualifications on SWB. The analysis demonstrates both a practical use of a modified LSF, and the value of taking a gender-specific approach to analysing wellbeing.

Retrospective review of intervention for traumatic blunt spleen injuries in adolescents by trauma center type.

BACKGROUND: Management guidelines for pediatric blunt spleen injuries (BSI) include adolescent patients but few studies have compared current management of adolescents with respect to other age groups by center type. METHODS: A retrospective review of 2017-2018 National Trauma Quality Improvement (TQIP) data of children (6-12), adolescents (13-17) and young adults (18-24) with BSI presenting to an adult, pediatric only, or adult/pediatric trauma center, comparing the rate of splenic intervention for adolescents by trauma center was performed. RESULTS: Children had lower odds of spleen intervention than adolescents at both adult (OR 0.61 95%CI 0.39, 0.95) and adult/pediatric (OR 0.55 95%CI 0.35, 0.87) centers but did not differ at pediatric centers (OR 0.94 95%CI 0.39, 2.2) (n = 10,494). Adolescents adjusted odds of intervention was equal to adults at adult trauma centers (OR 1.2 95%CI 0.95, 1.4). CONCLUSION: Adolescents are more likely to undergo interventions for BSI as compared to children at both adult and adult/pediatric trauma centers.

The Children's Anti-inflammatory Reliever (CARE) study: a protocol for a randomised controlled trial of budesonide-formoterol as sole reliever therapy in children with mild asthma.

BACKGROUND: Asthma is the most common chronic disease in children, many of whom are managed solely with a short-acting ß2-agonist (SABA). In adults, the evidence that budesonide-formoterol as sole reliever therapy markedly reduces the risk of severe exacerbations compared with SABA alone has contributed to the Global Initiative for Asthma recommending against SABA monotherapy in this population. The current lack of evidence in children means it is unknown whether these findings are also relevant to this demographic. High-quality randomised controlled trials (RCTs) are needed. OBJECTIVE: The aim of this study is to determine the efficacy and safety of as-needed budesonide-formoterol therapy compared with as-needed salbutamol in children aged 5 to 15 years with mild asthma, who only use a SABA. METHODS: A 52-week, open-label, parallel group, phase III RCT will recruit 380 children aged 5 to 15 years with mild asthma. Participants will be randomised 1:1 to either budesonide-formoterol (Symbicort Rapihaler®) 50/3 µg, two actuations as needed, or salbutamol (Ventolin®) 100  µg, two actuations as needed. The primary outcome is asthma attacks as rate per participant per year. Secondary outcomes assess asthma control, lung function, exhaled nitric oxide and treatment step change. A cost-effectiveness analysis is also planned. CONCLUSION: This is the first RCT to assess the safety and efficacy of as-needed budesonide-formoterol in children with mild asthma. The results will provide a much-needed evidence base for the treatment of mild asthma in children.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Trainee Utilization of the SCORE Curriculum is Associated With Improved ABSITE Performance: A Multi-institutional Study.

BACKGROUND: The Surgical Council on Resident Education's (SCORE) structured educational curriculum for general surgery residents uses a 2-year repeating cycle of modules and quizzes called "This Week in SCORE" (TWIS) to organize and sequence the curricular content on the SCORE portal. The purpose of this study was to evaluate the impact of using the SCORE content and TWIS curriculum on American Board of Surgery In-Training Examination (ABSITE) performance. To date, no multi-institutional studies have examined this effect. METHODS: Eight residency programs participated, including university and community-based programs. SCORE usage overall, TWIS usage, and ABSITE percentile scores (adjusted for post-graduate year [PGY]) were analyzed for the academic years 2017 to 2020. SCORE usage was defined as number of SCORE logins annually per resident with "low usage" ≤10 times and "high usage" >10 times. TWIS usage was defined as "low usage" (no TWIS quizzes done) or "high usage" (≥1 TWIS quiz per year). RESULTS: Four hundred and twenty-eight trainees were evaluated. Trainees with high SCORE and TWIS usage consistently achieved a higher ABSITE percentile score. This difference was maintained in subgroup analysis by PGY with the greatest impact in PGY-1 and PGY-2 levels. CONCLUSIONS: Utilization of multiple aspects of SCORE content appears to have a significant positive impact on ABSITE performance across all levels of postgraduate training. This multi-institutional study of a large number of users is the first to demonstrate that increased usage of SCORE content appears to be a predictor of ABSITE performance success.

Evaluation of a High-risk Patient Reminder System for Colonoscopy Surveillance.

Objectives: In this paper we report the evaluation of a proprietary recall system for promoting compliance with recommended follow-up in high-risk patients. Methods: We conducted a retrospective chart review for patients of an active private colon and rectal surgery practice having colonoscopy in 2006. Patients selected were <80 years of age and assessed to be high-risk by findings at exam or personal/family history of colorectal neoplasm with a recommendation for follow-up surveillance colonoscopy ranging from months to 5 years. Up to 6 months from recommendation was considered to be within compliance. Results: A total of 795 patients met the inclusion criteria, with average age of 63.2 years, 422 (53.1%) being men. Compliance with surveillance colonoscopy recommendations was 62.5%. The recall system impacted patient behavior with compliant patients being sent a median of one letter (average, 1.5) and late or no follow-up patients being sent a median of 4 letters (average, 3.9). Conclusions: Multiple contacts with patients are required to improve compliance with surveillance. Our findings support at least 4 to 5 efforts to remind patients of the importance to schedule a colonoscopy is necessary to optimize compliance.

Impact of improved insulation and heating on mortality risk of older cohort members with prior cardiovascular or respiratory hospitalisations.

OBJECTIVES: We carried out an evaluation of a large-scale New Zealand retrofit programme using administrative data that provided the statistical power to assess the effect of insulation and/or heating retrofits on cardiovascular and respiratory-related mortality in people aged 65 and over with prior respiratory or circulatory hospitalisations. DESIGN: Quasi-experimental cohort study based on administrative data. SETTING: New Zealand. PARTICIPANTS: From a larger study cohort of over 900 000 people, we selected two subcohorts: 3287 people who were aged 65 and over and had experienced pretreatment period cardiovascular-related hospitalisation (ICD-10 chapter 9), and 1561 people aged 65 and over who had experienced pretreatment respiratory-related hospitalisation (ICD-10 chapter 10). INTERVENTIONS: Treatment group individuals lived in a home that received insulation and/or heating retrofits under the Warm Up New Zealand: Heat Smart programme. Control group individuals lived in a home that was matched to a treatment home based on physical characteristics and location. PRIMARY AND SECONDARY OUTCOME MEASURES: HR for all-cause mortality for treatment with insulation, heating, or insulation and heating relative to control group. RESULTS: People with pretreatment circulatory hospitalisation who occupied a household that received only insulation had an HR for all-cause mortality of 0.673 (95% CI 0.535 to 0.847) (p<0.001) relative to control group members. Individuals with a pretreatment respiratory hospitalisation who occupied a household that received only an insulation retrofit had an HR for all-cause mortality of 0.830 (95% CI 0.655 to 1.051) (p=0.122) relative to control group members. There was no evidence of an additional benefit from receiving heating. CONCLUSIONS: We interpret the hazard rate observed for cardiovascular subcohort individuals who received insulation as evidence of a protective effect, reducing the risk of mortality for vulnerable older adults. There is suggestive evidence of a protective effect of insulation for the respiratory subcohort.