Outcomes in Obese Adult Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review.

Obesity is associated with an overall increased risk of morbidity and mortality. However, in patients with critical illness, sepsis, and acute respiratory distress syndrome, obesity may be protective, termed "the obesity paradox." This is a systematic literature review of articles published from 2000 to 2022 evaluating complications and mortality in adults with respiratory failure on veno-venous extracorporeal membrane oxygenation (VV ECMO) based on body mass index (BMI). Eighteen studies with 517 patients were included. Common complications included acute renal failure (175/377, 46.4%), venous thrombosis (175/293, 59.7%), and bleeding (28/293, 9.6%). Of the six cohort studies, two showed improved mortality among obese patients, two showed a trend toward improved mortality, and two showed no difference. Comparing all patients in the studies with BMI of less than 30 to those with BMI of greater than or equal to 30, we noted decreased mortality with obesity (92, 37.1% of BMI <30 vs. 30, 11% of BMI ≥30, p ≤ 0.0001). Obesity may be protective against mortality in adult patients undergoing VV ECMO. Morbid and super morbid obesity should not be considered a contraindication to cannulation, with patients with BMI ≥ 80 surviving to discharge. Complications may be high, however, with higher rates of continuous renal replacement therapy and thrombosis among obese patients.

Perioperative Management of Patients Undergoing Total Pancreatectomy with/without Islet Cell Autotransplantation: A Single Center Experience.

Total pancreatectomy (TP) and islet cell autotransplantation (IAT) are complex operations that require intensive postoperative monitoring with standardized protocols. There are few studies detailing immediate perioperative management. The purpose of this study was to describe the perioperative management of post-pancreatectomy patients in the first week following surgery to guide clinicians in addressing salient points from different organ systems. This is a retrospective cohort review of prospectively collected data from September 2017 to September 2022 at a single institution, including patients 16 years and older who underwent TP or TPIAT for chronic pancreatitis. Patients were maintained on a heparin drip (TPIAT), insulin drip, and ketamine infusion. Primary outcomes were complications in the first 5 days following surgery and ICU length of stay (LOS). Secondary outcomes included overall LOS and mortality. Of 31 patients, 26 underwent TPIAT, and 5 underwent TP. Median ICU LOS was five days (IQR 4-6). The most common immediate postoperative complications were reintubation [n = 5 (16%)] and bleeding [n = 2 (6%)]. Median insulin drip use was 70 h (IQR 20-124). There was no mortality. Patients were extubated quickly and progressed well on the protocol. Immediate postoperative complications were generally minor and without long-term effects.

Evaluation of Complications and Weight Outcomes in Pediatric Cerebral Palsy Patients With Gastrostomy Tubes.

BACKGROUND: Feeding difficulties are common in children with cerebral palsy (CP). The goal of this study was to examine pediatric CP patients undergoing gastrostomy tube (G tube) placement and assess the association between patient characteristics and weight after 3 months, 6 months, and 1 year. METHODS: This was a retrospective study of all pediatric patients with CP who received a G tube placement between April 2014 and December 2017 at a single institution. Bivariate analysis was used to examine association between patient characteristics and the primary outcome of improvement in weight Z score at 3, 6, and 12 months. RESULTS: Of 63 patients who received a G tube, 81% had an increase in Z score at 3 months, 44% at 6 months, and 64% at 12 months. By 12 months, factors associated with a positive Z score change included moderate and severe malnutrition, lack of prior G tube, and fewer comorbidities. The majority (69.8%) of patients experienced complications. Seven (11%) patients died, with only 1 death related to G tube placement. DISCUSSION: The use of G tubes in CP patients resulted in an increase in an improvement in nutritional status for the majority of patients over the course of a year. Although most complications were minor, patients had a high complication rate and frequently visited the emergency department, highlighting the need for standardized education and follow-up among this patient population.

The role of extracorporeal membrane oxygenation in adult kidney transplant patients: A qualitative systematic review of literature.

BACKGROUND: A paucity of evidence exists regarding the risks and benefits of Extracorporeal Membrane Oxygenation (ECMO) in adult kidney transplantation. METHODS: This was a systematic review conducted from Jan 1, 2000 to April 24, 2020 of adult kidney transplant recipients (pre- or post- transplant) and donors who underwent veno-arterial or veno-venous ECMO cannulation. Death and graft function were the primary outcomes, with complications as secondary outcomes. RESULTS: Twenty-three articles were identified that fit inclusion criteria. 461 donors were placed on ECMO, with an overall recipient 12-month mortality rate of 1.3% and a complication rate of 61.5%, the majority of which was delayed graft function. Fourteen recipients were placed on ECMO intraoperatively or postoperatively, with infection as the most common indication for ECMO. The 90-day mortality rate for recipients on ECMO was 42.9%, with multisystem organ failure and infection as the ubiquitous causes of death. 35.7% of patients experienced rejection within 6 months of decannulation, yet all were successfully treated. CONCLUSIONS: ECMO use in adult kidney transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO mirrors that of recipients from standard criteria donors. The morbidity and mortality of recipients placed on ECMO are also similar to other patient populations requiring ECMO.

Healthcare Disparity Education for Surgical Residents: Progress Made, More Needed.

BACKGROUND: Healthcare disparities are an important determinant of patient outcomes yet are not standardized within surgical resident education. This study aimed to determine the prevalence and design of current healthcare disparities curricula for surgical residents and included a resident-based needs assessment at a single institution. STUDY DESIGN: A national survey evaluating the presence and design of healthcare disparities curricula was distributed to general surgery program directors via the Association of Program Directors in Surgery Listserv. A related survey was administered to all general surgery residents at a single academic institution. RESULTS: One hundred forty-six program directors completed the survey, with 68 (47%) reporting an active curriculum. The most frequently taught topic is regarding patient race as a healthcare disparity, found in 63 (93%) of existing curricula. Fifty-two (76%) of the curricula were implemented within the last 3 years. Of the 78 (53%) programs without a curriculum, 8 (10%) program directors stated that their program would not benefit from one. Thirty-four (45%) of the programs without a curriculum cited institutional support and time as the most common barriers to implementation. Of the 23 residents who completed the survey, 100% desired learning practical knowledge regarding healthcare disparities relating to how race and socioeconomic status affect the clinical outcomes of surgical patients. CONCLUSIONS: Less than half of general surgery training programs have implemented healthcare disparities curricula. Resident preferences for the format and content of curricula may help inform program leaders and lead to comprehensive national standards.

Comparative outcomes between COVID-19 and influenza patients placed on veno-venous extracorporeal membrane oxygenation for severe ARDS.

BACKGROUND: ECMO is an established supportive adjunct for patients with severe, refractory ARDS from viral pneumonia. However, the exact role and timing of ECMO for COVID-19 patients remains unclear. METHODS: We conducted a retrospective comparison of the first 32 patients with COVID-19-associated ARDS to the last 28 patients with influenza-associated ARDS placed on V-V ECMO. We compared patient factors between the two cohorts and used survival analysis to compare the hazard of mortality over sixty days post-cannulation. RESULTS: COVID-19 patients were older (mean 47.8 vs. 41.2 years, p = 0.033), had more ventilator days before cannulation (mean 4.5 vs. 1.5 days, p < 0.001). Crude in-hospital mortality was significantly higher in the COVID-19 cohort at 65.6% (n = 21/32) versus 36.3% (n = 11/28, p = 0.041). The adjusted hazard ratio over sixty days for COVID-19 patients was 2.81 (95% CI 1.07, 7.35) after adjusting for age, race, ECMO-associated organ failure, and Charlson Comorbidity Index. CONCLUSION: ECMO has a role in severe ARDS associated with COVID-19 but providers should carefully weigh patient factors when utilizing this scarce resource in favor of influenza pneumonia.

The role of extracorporeal membrane oxygenation in adult liver transplant patients: A qualitative systematic review of literature.

BACKGROUND: A paucity of evidence exists regarding risks and benefits of extracorporeal membrane oxygenation (ECMO) in adult liver transplantation. METHODS: This was a systematic review conducted from January 1, 2000 to April 24, 2020 of adult liver transplant recipients (pre- or post-transplant) and donors who underwent Veno-arterial or Veno-venous ECMO cannulation. Death was the primary outcome, with graft function and complications as secondary outcomes. RESULTS: Forty-one articles were identified that fit criteria. A total of 183 donors were placed on ECMO, with recipient complication profiles and mortality that mirrored rates from standard criteria donors. Sixty-one recipients were placed on ECMO intraoperatively or postoperatively. Most patients experienced at least one complication with infections as the most common cause and minimal complications specifically related to ECMO use. Multisystem organ failure (MSOF) and infections were more common among liver recipients who died compared to those who survived. Overall mortality at 90 days was 45.9%. Causes of death were most commonly MSOF and infections. CONCLUSIONS: ECMO use in adult liver transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO parallel that of recipients from standard criteria donors, and morbidity and mortality of recipients placed on ECMO are similar to other ECMO populations.

Socioeconomic disparities in ostomy reversal among older adults with diverticulitis are more substantial among non-Hispanic Black patients.

BACKGROUND: While ostomies for diverticulitis are often intended to be temporary, ostomy reversal rates can be as low as 46%. There are few comprehensive studies evaluating the effects of socioeconomic status as a disparity in ostomy reversal. We hypothesized that among the elderly Medicare population undergoing partial colectomy for diverticulitis, lower socioeconomic status would be associated with reduced reversal rates. METHODS: Retrospective cohort study using a 20% representative sample of Medicare beneficiaries >65 years old with diverticulitis who received ostomies between January 1, 2010, to December 31, 2017. We evaluated the effect of neighborhood socioeconomic status, measured by the Social Deprivation Index, on ostomy reversal within 1 year. Secondary outcomes were complications and mortality. RESULTS: Of 10,572 patients, ostomy reversals ranged from 21.2% (low socioeconomic status) to 29.8% (highest socioeconomic status), with a shorter time to reversal among higher socioeconomic status groups. Patients with low socioeconomic status were less likely to have their ostomies reversed, compared with the highest socioeconomic status group (hazard ratio 0.83, 95% confidence interval 0.74-0.93) and were more likely to die (hazard ratio 1.21, 95% confidence interval 1.10-1.33). When stratified by race/ethnicity and socioeconomic status, non-Hispanic White patients at every socioeconomic status had a higher reversal rate than non-Hispanic Black patients (White patients 32.0%-24.8% vs Black patients 19.6%-14.7%). Socioeconomic status appeared to have a higher relative impact among non-Hispanic Black patients. CONCLUSION: Among Medicare diverticulitis patients, ostomy reversal rates are low. Patients with lower socioeconomic status are less likely to undergo stoma reversal and are more likely to die; Black patients are least likely to have an ostomy reversal.

The role of extracorporeal membrane oxygenation in pediatric abdominal transplant patients: A qualitative systematic review of literature.

BACKGROUND: Advances in ECMO have made it a useful adjunct in critically ill pediatric patients; however, a dearth of evidence exists regarding risks and benefits in pediatric abdominal transplantation. The purpose of this study was to perform a qualitative systematic review of outcomes in pediatric patients undergoing ECMO support pre- or post-abdominal organ transplantation. METHODS: This was a systematic review conducted from Jan 1, 1989, to April 24, 2020, via PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and ClinicalTrials.gov of all pediatric solid abdominal organ transplant recipients (pre- and post-transplant) and donors who underwent V-A or V-V ECMO cannulation. Death was the primary outcome, with graft function and complications as secondary outcomes. RESULTS: Fourteen articles were identified that fit criteria, with 88% being case reports. Three patients were donors placed on ECMO, with no mortality among the 8 recipients of organs from these donors. Nineteen recipients were placed on ECMO. All were liver transplants. Most patients experienced at least one complication (84%), with bleeding as the most common cause (44%). Mortality was 26%. Causes of death included multiorgan system failure (n = 3), heart failure (n = 1), Systemic inflammatory response syndrome (n = 1), abdominal compartment syndrome (n = 3), bleeding (n = 1), septic shock from aspergillus (n = 1), and hepatic artery thrombosis (n = 2). CONCLUSIONS: The data are poor on ECMO usage in pediatric abdominal transplantation. While complications were high, mortality did not appear to be related to ECMO usage and was relatively low given the severity of patient illness.

Does Level of Blood Alcohol Content Affect Clinical Outcomes After Trauma in Older Adult Patients?

INTRODUCTION: Preinjury alcohol use and older age have independently been associated with poor outcomes. This study examined whether higher levels of blood alcohol concentration (BAC) correlated with an increased likelihood of poor outcomes in older trauma patients. METHODS: This was a retrospective cohort study of injured patients ≥65 years with BAC testing presenting to a Level 1 trauma center between 2015 and 2018. Patients were stratified by BAC at 4 thresholds of intoxication: BAC ≧10 mg/dL, BAC ≧80 mg/dL, BAC ≧150 mg/dL, and BAC ≧200 mg/dL. Propensity score matching using inverse probability of treatment weighting was used to estimate outcomes. Logistic and Poisson regression models were performed for each threshold of the BAC level with the matched cohort to assess clinical outcomes. RESULTS: Of all older patients (n = 3112), 32.5% (n = 1012) had BAC testing. In the matched cohort of 883 patients (76.7 ± 8.2 years; 48.1% female), 111 (12.5%) had BAC ≧10 mg/dL, 83 (74.8%) had BAC ≧80 mg/dL, 60 (54.1%) had BAC ≧150 mg/dL, and 37 (33.3%) had BAC ≧200 mg/dL. Falls (60.5%) and motor vehicle crashes (28.9%) were the most common mechanisms of injury. Median (IQR) of Injury Severity Score (ISS) was 5 (1-10). The risk of severe injury (ISS ≧15) was similar between alcohol-positive and alcohol-negative patients (9.9% vs 15.0%, P = .151). BAC ≧10 g/dL was not associated with length of stay, intensive care unit admission, or in-hospital complication, nor was any of the other 3 analyzed BAC thresholds. CONCLUSION: Overall, any detectable BAC along and increasing thresholds of BAC was not associated with poor in-hospital outcomes of older patients after trauma. Alcohol screening was low in this population, and intoxication may bias injury assessment, leading to mistriage of older trauma patients.

Secondary Overtriage of Trauma Patients to a Central Hospital in Malawi.

INTRODUCTION: Secondary overtriage (OT) is the unnecessary transfer of injured patients between facilities. In low- and middle-income countries (LMICs), which shoulder the greatest burden of trauma globally, the impact of wasted resources on an overburdened system is high. This study determined the rate and associated characteristics of OT at a Malawian central hospital. METHODS: A retrospective analysis of prospectively collected data from January 2012 through July 2017 was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Patients were considered OT if they were discharged alive within 48 h without undergoing a procedure, and were not severely injured or in shock on arrival. Factors evaluated for association with OT included patient demographics, injury characteristics, and transferring facility information. RESULTS: Of 80,915 KCH trauma patients, 15,422 (19.1%) transferred from another facility. Of these, 8703 (56.2%) were OT. OT patients were younger (median 15, IQR: 6-31 versus median 26, IQR: 11-38, p < 0.001). Patients with primary extremity injury (5308, 59.9%) were overtriaged more than those with head injury (1991, 51.8%) or torso trauma (1349, 50.8%), p < 0.001. The OT rate was lower at night (18.9% v 28.7%, p < 0.001) and similar on weekends (20.4% v 21.8%, p = 0.03). OT was highest for penetrating wounds, bites, and falls; burns were the lowest. In multivariable modeling, risk of OT was greatest for burns and soft tissue injuries. CONCLUSIONS: The majority of trauma patients who transfer to KCH are overtriaged. Implementation of transfer criteria, trauma protocols, and interhospital communication can mitigate the strain of OT in resource-limited settings.

Sex Disparities in Access to Surgical Care at a Single Institution in Malawi.

INTRODUCTION: There is a paucity of data regarding sex-based disparities in surgical care delivery, particularly in low- and middle-income countries. This study sought to determine whether sex disparities are present among patients presenting with surgical conditions in Malawi. Hypothesis compared to men, fewer women present to Kamuzu Central Hospital (KCH) with peritonitis and have longer delays in presentation for definitive care. METHODS: This study performs a retrospective analysis of prospectively collected data of all general surgery patients with peritonitis presenting to KCH in Lilongwe, Malawi, from September 2013 to April 2016. Multivariable linear and logistic regressions were used to assess the effect of sex on mortality, length of stay, operative intervention, complications, and time to presentation. RESULTS: Of 462 patients presenting with general surgery conditions and peritonitis, 68.8% were men and 31.2% were women. After adjustments, women had significantly higher odds of non-operative management when compared to men (OR 2.17, 95%CI 1.30-3.62, P = 0.003), delays in presentation (adjusted mean difference 136 h, 95%CI 100-641, P = 0.05), delays to operation (adjusted mean difference 1.91 days, 95%CI 1.12-3.27, P = 0.02), and longer lengths of stay (adjusted mean difference 1.67 days, 95%CI 1.00-2.80, P = 0.05). There were no differences in complications or in-hospital or Emergency Department mortality. CONCLUSION: Sex disparities exist within the general surgery population at KCH in Lilongwe, Malawi. Fewer women present with surgical problems, and women experience delays in presentation, longer lengths of stay, and undergo fewer operations. Future studies to determine mortality in the community and driving factors of sex disparities will provide more insight.

Interpersonal violence in peacetime Malawi.

BACKGROUND: The contribution of interpersonal violence (IPV) to trauma burden varies greatly by region. The high rates of IPV in sub-Saharan Africa are thought to relate in part to the high rates of collective violence. Malawi, a country with no history of internal collective violence, provides an excellent setting to evaluate whether collective violence drives the high rates of IPV in this region. METHODS: This is a retrospective review of a prospective trauma registry from 2009 through 2016 at Kamuzu Central Hospital in Lilongwe, Malawi. Adult (>16 years) victims of IPV were compared with non-intentional trauma victims. Log binomial regression determined factors associated with increased risk of mortality for victims of IPV. RESULTS: Of 72 488 trauma patients, 25 008 (34.5%) suffered IPV. Victims of IPV were more often male (80.2% vs. 74.8%; p<0.001), younger (median age: 28 years (IQR: 23-34) vs. 30 years (IQR: 24-39); p<0.001), and were more often admitted at night (47.4% vs. 31.9%; p<0.001). Of the IPV victims, 16.5% admitted alcohol use, compared with only 4.4% in other trauma victims (p<0.001). In regression modeling, compared with extremity injuries, head injuries (3.14, 2.24-4.39; p<0.001) and torso injuries (4.32, 2.98-6.27; p<0.001) had increased risk of mortality. Compared with other or unknown mechanisms, penetrating injuries also had increased risk of mortality (1.46, 95% CI 1.17 to 1.81, p=0.001). Alcohol use was associated with a lower risk of mortality (0.54, 95% CI 0.39 to 0.75; p<0.001). DISCUSSION: Even in a sub-Saharan country that never experienced internal collective violence, IPV injury rates are high. Public health efforts to measure and address alcohol use, and studies to determine the role of "mob justice," poverty, and intimate partner violence in IPV, in Malawi are needed. LEVEL OF EVIDENCE: Level III.