Lower Socioeconomic Status Predicts Greater Obstacles to Care: Using Outpatient Cholecystectomy as a Model Cohort.

BACKGROUND: Patients with low socioeconomic status (SES) are disadvantaged in terms of access to health care. A novel metric for SES is the Distressed Communities Index (DCI). This study evaluates the effect of DCI on hospital choice and distance traveled for surgery. METHODS: A Florida database was queried for patients with symptomatic cholelithiasis or chronic cholecystitis who underwent an outpatient cholecystectomy between 2016 and 2019. Patients' DCI was compared with hospital ratings, comorbidities, Charlson Comorbidity Index, and distance traveled for surgery. Stepwise logistic regression was used to determine which factors most influenced distance traveled for surgery. RESULTS: There were 54,649 cases-81 open, 52,488 laparoscopic, and 2,080 robotic. There was no difference between surgical approach and patient's DCI group (p = 0.12). Rural patients traveled the farthest for surgery (avg 21.29 miles); urban patients traveled the least (avg 5.84 miles). Patients from distressed areas more often had surgery at one- or two-star hospitals than prosperous patients (61% vs 36.3%). Regression indicated distressed or at-risk areas predicted further travel for rural/small-town patients, while higher hospital ratings predicted further travel for suburban/urban patients. DISCUSSION: Compared to prosperous areas, patients from distressed areas have surgery at lower-rated hospitals, travel further if they live in rural/small-town areas, but travel less if they live in suburban areas. We postulate that farther travel in rural areas may be explained by a lack of health care resources in poor, rural areas, while traveling less in suburban areas may be explained by personal lack of resources for patients with low SES.

Expanded analysis for patients with acute cholecystitis indicates outcomes vary based on COVID-19 status and treatment modality.

BACKGROUND: The impact of different phases of COVID-19 infection on outcomes from acute calculous cholecystitis (ACC) is not well understood. Therefore, we examined outcomes of acute cholecystitis during the COVID-19 pandemic, comparing the effect of different treatment modalities and COVID-19 infection status. We hypothesized that patients with acute COVID-19 would have worse outcomes than COVID-negative patients, but there would be no difference between COVID-negative and COVID-recovered patients. METHODS: We used 2020-2023 National COVID Cohort Collaborative data to identify adults with ACC. Treatment (antibiotics-only, cholecystostomy tube, or cholecystectomy) and COVID-19 status (negative, active, or recovered) were collected. Treatment failure of nonoperative managements was noted. Adjusted analysis using a series of generalized linear models controlled for confounders (age, sex, body mass index, Charlson comorbidity index, severity at presentation, and year) to better assess differences in outcomes among treatment groups, as well as between COVID-19 groups. RESULTS: In total, 32,433 patients (skewed count) were included: 29,749 COVID-negative, 2112 COVID-active, and 572 (skewed count) COVID-recovered. COVID-active had higher rates of sepsis at presentation. COVID-negative more often underwent cholecystectomy. Unadjusted, COVID-active had higher 30-day mortality, 30-day complication, and longer length of stay than COVID-negative and COVID-recovered. Adjusted analysis revealed cholecystectomy carried lower odds of mortality for COVID-active and COVID-negative patients than antibiotics or cholecystostomy. COVID-recovered patients' mortality was unaffected by treatment modality. Treatment failure from antibiotics was more common for COVID-negative patients. CONCLUSION: Acute cholecystitis outcomes are affected by phase of COVID-19 infection and treatment modality. Cholecystectomy does not lead to worse outcomes for COVID-active and COVID-recovered patients than nonoperative treatments; thus, these patients can be considered for cholecystectomy if their physiology is not prohibitive.

Survival Tree Provides Individualized Estimates of Survival After Lung Transplant.

INTRODUCTION: Identifying contributors to lung transplant survival is vital in mitigating mortality. To enhance individualized mortality estimation and determine variable interaction, we employed a survival tree algorithm utilizing recipient and donor data. METHODS: United Network Organ Sharing data (2000-2021) were queried for single and double lung transplants in adult patients. Graft survival time <7 d was excluded. Sixty preoperative and immediate postoperative factors were evaluated with stepwise logistic regression on mortality; final model variables were included in survival tree modeling. Data were split into training and testing sets and additionally validated with 10-fold cross validation. Survival tree pruning and model selection was based on Akaike information criteria and log-likelihood values. Estimated survival probabilities and log-rank pairwise comparisons between subgroups were calculated. RESULTS: A total of 27,296 lung transplant patients (8175 single; 19,121 double lung) were included. Stepwise logistic regression yielded 47 significant variables associated with mortality. Survival tree modeling returned six significant factors: recipient age, length of stay from transplant to discharge, recipient ventilator duration post-transplant, double lung transplant, recipient reintubation post-transplant, and donor cytomegalovirus status. Eight subgroups consisting of combinations of these factors were identified with distinct Kaplan-Meier survival curves. CONCLUSIONS: Survival trees provide the ability to understand the effects and interactions of covariates on survival after lung transplantation. Individualized survival probability with this technique found that preoperative and postoperative factors influence survival after lung transplantation. Thus, preoperative patient counseling should acknowledge a degree of uncertainty given the influence of postoperative factors.

Meta-Analysis in Surgical Research: Methodology and Statistical Application.

In evidence-based medicine, systematic review continues to carry the highest weight in terms of quality and reliability, synthesizing robust information from previously published cohort studies to provide a comprehensive overview of a topic. Meta-analysis provides further depth by allowing for comparative analysis between the studied intervention and the control group, providing the most up-to-date evidence on their characteristics and efficacy. We discuss the principles and methodology of meta-analysis, and its applicability to the field of surgical research. The clinical question is defined using PICO framework (Problem, Intervention, Comparison, Outcome). Then a systematic article search is performed across multiple medical databases using relevant search terms, which are then filtered out based on appropriate screening tools. Pertinent data from the selected articles are collected and undergo critical appraisal by at least two independent reviewers. Additional statistical tests may be performed to identify the presence of any significant bias. The data are then synthesized to perform comparative analysis between the intervention and comparison groups. In this article, we discuss specifically the usage of R software (R Foundation for Statistical Computing, Vienna, Austria) for data analysis and visualization. Meta-analysis results of the pooled data are presented using forest plots. Concerns for potential bias may be addressed through the creation of funnel plots. Meta-analysis is a powerful tool to provide highly reliable medical evidence. It may be readily performed by independent researchers with minimal need for funding or institutional approval. The ability to conduct such studies is an asset to budding medical scholars.

The continued financial effect of COVID: Increasing costs for non-elective major lower extremity amputations.

Background: The COVID-19 pandemic necessitated changes in processes of care, which significantly impacted surgical care. This study evaluated the impact of these changes on patient outcomes and costs for non-elective major lower extremity amputations (LEA). Methods: The 2019-2021 Florida Agency for Health Care Administration database was queried for adult patients who underwent non-elective major LEA. Per-patient inflation-adjusted costs were collected. Patient cohorts were established based on Florida COVID-19 mortality rates: COVID-heavy (CH) included nine months with the highest mortality, COVID-light (CL) included nine months with the lowest mortality, and pre-COVID (PC) included nine months before COVID (2019). Outcomes included in-hospital patient outcomes and hospitalization cost. Results: 6132 patients were included (1957 PC, 2104 CH, and 2071 CL). Compared to PC, there was increased patient acuity at presentation, but morbidity (31%), mortality (4%), and length of stay (median 12 [8-17] days) were unchanged during CH and CL. Additionally, costs significantly increased during the pandemic; median total cost rose 9%, room costs increased by 16%, ICU costs rose by 15%, and operating room costs rose by 15%. When COVID-positive patients were excluded, cost of care was still significantly higher during CH and CL. Conclusions: Despite maintaining pre-pandemic standards, as evidenced by unchanged outcomes, the pandemic led to increased costs for patients undergoing non-elective major LEA. This was likely due to increased patient acuity, resource strain, and supply chain shortages during the pandemic. Key message: While patient outcomes for non-elective major lower extremity amputations remained consistent during the COVID-19 pandemic, healthcare costs significantly increased, likely due to increased patient acuity and heightened pressures on resources and supply chains. These findings underscore the need for informed policy changes to mitigate the financial impact on patients and healthcare systems for future public health emergencies.

Cirrhosis Increases the Rate of Failure of Nonoperative Management in Blunt Liver Injuries.

Pre-existing cirrhosis is associated with increased mortality in blunt liver injury. Despite widespread use of nonoperative management (NOM) for blunt liver injury, there is a relative paucity of data regarding how pre-existing cirrhosis impacts the success of NOM. Herein, we perform a retrospective cohort study using ACS TQIP 2017-2020 data to assess the relationship between cirrhosis and failure of NOM for adult patients with blunt liver injury. 37,176 patients were included (342 cirrhosis and 36,834 without cirrhosis). After propensity-score matching, patients with pre-existing cirrhosis had higher rates of failure of NOM (32.2 vs 14.1%, p < 0.01) and in-hospital mortality (36.3 vs 10.8%, p < 0.01) than patients without cirrhosis. Hesitancy to operate on patients with pre-existing cirrhosis and trauma, as well as significant underlying coagulopathy, may explain these findings.

Initial Experience Using Laparoscopic HIPEC for Gastric Cancer with Peritoneal Metastasis: Safety and Outcomes.

BACKGROUND: Peritoneal metastases (PM) develop in approximately 20% of patients with gastric cancer (GC). For selected patients, treatment of PM with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has shown promising results. This report aims to describe the safety and perioperative outcomes of laparoscopic HIPEC for GC/PM. METHODS: This retrospective cohort study evaluated patients who had GC and PM treated with laparoscopic HIPEC (2018-2022). The HIPEC involved cisplatin and mitomycin C (MMC) or MMC alone. The primary end point was perioperative safety. RESULTS: The 22 patients in this study underwent 27 procedures. The mean age was 58 ± 13 years. All the patients were Eastern Cooperative Oncology Group (ECOG) 0 or 1 (55 and 45%, respectively). Five patients underwent a second laparoscopic HIPEC, with a median of 126 days (interquartile range [IQR], 117-166 days) between procedures. The median peritoneal carcinomatosis index (PCI) was 4 (IQR, 2-9), and the median hospital stay was 2 days (IQR, 1-3 days). No 30-day readmissions or complications occurred. Eight patients (36%) underwent gastrectomy (CRS ± HIPEC). After an average follow-up period of 11 months, 7 (32%) of the 22 patients were alive. The median overall survival was 11 months (IQR, 195-739 days) from the initial procedure and 19.3 months (IQR, 431-1204 days) from the diagnosis. CONCLUSIONS: Laparoscopic HIPEC appears to be safe with minimal perioperative complications. Approximately one third of the patients undergoing initial laparoscopic HIPEC ultimately proceeded to cytoreduction and gastrectomy. Preliminary survival data from this highly selected cohort suggest that the addition of laparoscopic HIPEC to systemic chemotherapy does not compromise other treatment options. These initial results suggest that laparoscopic HIPEC may offer benefit to patients with GC and PM and aid in the selection of patients who may benefit from curative-intent resection.

Transition to Permitless Open Carry and Association with Firearm-Related Suicide.

BACKGROUND: Firearm-related death rates continue to rise in the US. As some states enact more permissive firearm laws, we sought to assess the relationship between a change to permitless open carry (PLOC) and subsequent firearm-related death rates, a currently understudied topic. STUDY DESIGN: Using state-level data from 2013 to 2021, we performed a linear panel analysis using a state fixed-effects model. We examined total firearm-related death, suicide, and homicide rates separately. If a significant association between OC law and death rate was found, we then performed a difference-in-difference (DID) analysis to assess for a causal relationship between changing to PLOC and increased death rate. For significant DID results, we performed confirmatory DID separating firearm and nonfirearm death rates. RESULTS: Nineteen states maintained a no OC or permit-required law, whereas 5 changed to permitless and 26 had a PLOC before 2013. The fixed-effects model indicated more permissive OC law that was associated with increased total firearm-related deaths and suicides. In DID, changing law to PLOC had a significant average treatment effect on the treated of 1.57 (95% CI 1.05 to 2.09) for total suicide rate but no significant average treatment effect for the total firearm-related death rate. Confirmatory DID results found a significant average treatment effect on the treated of 1.18 (95% CI 0.90 to 1.46) for firearm suicide rate. CONCLUSIONS: OC law is associated with total firearm-related death and suicide rates. Based on our DID results, changing to PLOC is indeed strongly associated with increased suicides by firearm.

The downtrending cost of robotic bariatric surgery: a cost analysis of 47,788 bariatric patients.

The surgical robot is assumed to be a fixed, indirect cost. We hypothesized rising volume of robotic bariatric procedures would decrease cost per patient over time. Patients who underwent elective, initial gastric bypass (GB) or sleeve gastrectomy (SG) for morbid obesity were selected from Florida Agency for Health Care Administration database from 2017 to 2021. Inflation-adjusted cost per patient was collected. Cost-over-time ($/patient year) and change in cost-over-time were calculated for open, laparoscopic, and robotic cases. Linear regression on cost generated predictive parameters. Density plots utilizing area under the curve demonstrated cost overlap. Among 76 hospitals, 11,472 bypasses (223 open, 6885 laparoscopic, 4364 robotic) and 36,316 sleeves (26,596 laparoscopic, 9724 robotic) were included. Total cost for robotic was approximately 1.5-fold higher (p < 0.001) than laparoscopic for both procedures. For GB, laparoscopic had lower total ($15,520) and operative ($6497) average cost compared to open (total $17,779; operative $9273) and robotic (total $21,756; operative $10,896). For SG, laparoscopic total cost was significantly less than robotic ($10,691 vs. $16,393). Robotic GB cost-over-time increased until 2021, when there was a large decrease in cost (-$944, compared with 2020). Robotic SG total cost-over time fluctuated, but decreased significantly in 2021 (-$490 compared with 2020). While surgical costs rose significantly in 2020 for bariatric procedures, our study suggests a possible downward trend in robotic bariatric surgery as total and operative costs are decreasing at a higher rate than laparoscopic costs.

Is nonoperative management of appendicitis inferior in the COVID-19 era?

BACKGROUND: Previous studies on nonoperative management (NOM) of acute appendicitis (AA) indicated comparable outcomes to surgery, but the effect of COVID-19 infection on appendicitis outcomes remains unknown. Thus, we evaluate appendicitis outcomes during the COVID-19 pandemic to determine the effect of COVID-19 infection status and treatment modality. We hypothesized that active COVID-19 patients would have worse outcomes than COVID-negative patients, but that outcomes would not differ between recovered COVID-19 and COVID-negative patients. Moreover, we hypothesized that outcomes would not differ between nonoperative and operative management groups, regardless of COVID-19 status. METHODS: We queried the National COVID Cohort Collaborative from 2020 to 2023 to identify adults with AA who underwent operative or NOM. COVID-19 status was denoted as follows: COVID-negative, COVID-active, or COVID-recovered. Intention to treat was used for NOM. Propensity score-balanced analysis was performed to compare outcomes within COVID groups, as well as within treatment modalities. RESULTS: A total of 37,868 patients were included: 34,866 COVID-negative, 2,540 COVID-active, and 460 COVID-recovered. COVID-active and recovered less often underwent operative management. Unadjusted, there was no difference in mortality between COVID groups for operative management. There was no difference in rate of failure of NOM between COVID groups. Adjusted analysis indicated, compared with operative, NOM carried higher odds of mortality and readmission for COVID-negative and COVID-active patients. CONCLUSION: This study demonstrates higher odds of mortality among NOM of appendicitis and near equivalent outcomes for operative management regardless of COVID-19 status. We conclude that NOM of appendicitis is associated with worse outcomes for COVID-active and COVID-negative patients. In addition, we conclude that a positive COVID test or recent COVID-19 illness alone should not preclude a patient from appendectomy for AA. Surgeon clinical judgment of a patient's physiology and surgical risk should, of course, inform the decision to proceed to the operating room. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Corrigendum to "Association of state-level factors with rate of firearm-related deaths" [Surg. Open Sci. vol. 14 (2023) 114-119].

[This corrects the article DOI: 10.1016/j.sopen.2023.07.011.].

Patient outcomes and cost in robotic emergency general surgery.

The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24 h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.

Association of state-level factors with rate of firearm-related deaths.

Background: Over 48,000 people died by firearm in the United States in 2021. Firearm violence has many inciting factors, but the full breadth of associations has not been characterized. We explored several state-level factors including factors not previously studied or insufficiently studied, to determine their association with state firearm-related death rates. Methods: Several state-level factors, including firearm open carry (OC) and concealed carry (CC) laws, state rank, partisan lean, urbanization, poverty rate, anger index, and proportion of college-educated adults, were assessed for association with total firearm-related death rates (TFDR). Secondary outcomes were firearm homicide (FHR) and firearm suicide rates (FSR). Exploratory data analysis with correlation plots and ANOVA was performed. Univariable and multivariable linear regression on the rate of firearm-related deaths was also performed. Results: All 50 states were included. TFDR and FSR were higher in permitless OC and permitless CC states. FHR did not differ based on OC or CC category. Open carry and CC were eliminated in all three regression models due to a lack of significance. Significant factors for each model were: 1) TFDR - partisan lean, urbanization, poverty rate, and state ranking; 2) FHR - poverty rate; 3) FSR - partisan lean and urbanization. Conclusions: Neither open nor concealed carry is associated with firearm-related death rates when socioeconomic factors are concurrently considered. Factors associated with firearm homicide and suicide differ and will likely require separate interventions to reduce firearm-related deaths. Key message: Neither open carry nor concealed carry law are associated with total firearm-related death rate, but poverty rate, urbanization, partisan lean, and state ranking are associated. When analyzing firearm homicide and suicide rates separately, poverty rate is strongly associated with firearm homicide rate, while urbanization and partisan lean are associated with firearm suicide rate.

COVID-Induced Alterations in Surgical Care and Outcomes in Perforated Diverticulitis.

BACKGROUND: COVID-19 caused healthcare systems to significantly alter processes of care. Literature on the pandemic's effect on healthcare processes and resulting surgical outcomes is lacking. This study aims to determine outcomes of open colectomy in patients with perforated diverticulitis during the pandemic. METHODS: Using CDC data, the highest and lowest COVID mortality rates were calculated and used to establish 9-month COVID-heavy (CH) and COVID-light (CL) timeframes, respectively. Nine-months of 2019 were assigned as pre-COVID (PC) control. Florida AHCA database was utilized for patient-level data. Primary outcomes were length of stay (LOS), morbidity, and in-hospital mortality. Stepwise regression with 10-fold cross-validation determined factors most impacting outcomes. A parallel analysis excluding COVID-positive patients was performed to differentiate COVID-infection from processes of care. RESULTS: There were 3862 patients in total. COVID-positive patients had longer LOS, more intensive care unit admissions, and higher morbidity and mortality. After excluding 105 COVID-positive patients, individual outcomes were not different per timeframe. Regression showed timeframe did not affect primary outcomes. DISCUSSION: Outcomes following colectomy for perforated diverticulitis were worse for COVID-positive patients. Despite increased stress on the healthcare system during the pandemic, major outcomes were unchanged for COVID-negative patients. Our results indicate that despite COVID-associated changes in processes of care, acute care surgery can still be performed in COVID-negative patients without increased mortality and minimal change in morbidity.

Causal analysis of socioeconomic influence on cost of care: The emergency general surgery model.

BACKGROUND: This study characterizes the relationship between SES and cost of emergency general surgery (EGS). METHODS: Utilizing Florida AHCA (2016-2020), patients undergoing the 7 most common EGS were identified. Distressed Community Index (DCI) was linked, which quantifies SES through unemployment, poverty, and other factors. Zipcodes are assigned DCI 0 (no distress) to 100 (severe distress). Linear regression with stepwise elimination was conducted. Top and bottom DCI quintiles were propensity matched for demographics, comorbidities, and procedure. RESULTS: 144,924 admissions were included. Linear regression eliminated 5 of 28 variables, including DCI. Top cost contributors were discharge-43%; comorbidities-14%; age-9%. Distressed patients received less home health and inpatient rehab. Distressed patients utilized 4-/5-star hospitals less and had higher odds of mortality. CONCLUSION: Discharge, mortality, and hospital characteristics differ significantly between DCI communities. Total cost was similar, and is strongly influenced by discharge status, while DCI had no effect.

Analysis of temporal trends in robotic surgery costs using the outpatient inguinal hernia repair model.

BACKGROUND: Robotic technology is increasingly utilized despite increased costs compared with laparoscopic procedures. As the robot is a fixed, indirect cost, we hypothesized increased volume of robotic procedures will decrease operative costs per patient. The model of same-day, unilateral, primary inguinal hernia surgery in males was chosen. METHODS: The Florida Agency for Health Care Administration database was queried for inguinal hernia repairs from 2015 to 2020. Inflation adjusted total and operative costs per patient were collected. Cost-over-time and change in cost-over-time were calculated for open, laparoscopic, and robotic cases. Linear regression using cost as the dependent variable generated predictive parameters. RESULTS: In the study, 36,393 cases (19,364 open, 12,322 laparoscopic, 4,707 robotic) among 86 hospitals were included. In addition, 18 hospitals were "high volume," defined as total robotic inguinal hernia volume of >100 (range, 107-368) during the study period, and included 8,604 cases (3,915 open, 1,786 laparoscopic, 2,903 robotic). Compared with laparoscopic, total robotic cost and cost over time were 1.22- (P < .001) and 1.5-fold higher (P < .002). The change in cost-over-time was increased significantly in robotic cases: 358, 420, 548, 691, and 1,542 cost-over-time for 2015 to 2020, respectively. Positive contributors to total hospital robotic costs were total robotic inguinal hernia volume (17.3), total laparoscopic inguinal hernia volume (12.6), and number of hospital beds (1.9). Total open inguinal hernia volume was a negative contributor (-10). CONCLUSION: We conclude, in the short term, robotic surgical costs are not behaving as traditional fixed costs in outpatient, unilateral inguinal hernia surgeries. Hospital methodology for cost assignment and increased robotic fixed costs such as purchase of additional instruments may explain these results.

Nonelective coronary artery bypass graft outcomes are adversely impacted by Coronavirus disease 2019 infection, but not altered processes of care: A National COVID Cohort Collaborative and National Surgery Quality Improvement Program analysis.

Objective: The effects of Coronavirus disease 2019 (COVID-19) infection and altered processes of care on nonelective coronary artery bypass grafting (CABG) outcomes remain unknown. We hypothesized that patients with COVID-19 infection would have longer hospital lengths of stay and greater mortality compared with COVID-negative patients, but that these outcomes would not differ between COVID-negative and pre-COVID controls. Methods: The National COVID Cohort Collaborative 2020-2022 was queried for adult patients undergoing CABG. Patients were divided into COVID-negative, COVID-active, and COVID-convalescent groups. Pre-COVID control patients were drawn from the National Surgical Quality Improvement Program database. Adjusted analysis of the 3 COVID groups was performed via generalized linear models. Results: A total of 17,293 patients underwent nonelective CABG, including 16,252 COVID-negative, 127 COVID-active, 367 COVID-convalescent, and 2254 pre-COVID patients. Compared to pre-COVID patients, COVID-negative patients had no difference in mortality, whereas COVID-active patients experienced increased mortality. Mortality and pneumonia were higher in COVID-active patients compared to COVID-negative and COVID-convalescent patients. Adjusted analysis demonstrated that COVID-active patients had higher in-hospital mortality, 30- and 90-day mortality, and pneumonia compared to COVID-negative patients. COVID-convalescent patients had a shorter length of stay but a higher rate of renal impairment. Conclusions: Traditional care processes were altered during the COVID-19 pandemic. Our data show that nonelective CABG in patients with active COVID-19 is associated with significantly increased rates of mortality and pneumonia. The equivalent mortality in COVID-negative and pre-COVID patients suggests that pandemic-associated changes in processes of care did not impact CABG outcomes. Additional research into optimal timing of CABG after COVID infection is warranted.

Survivor of Right Atrial Appendage Rupture Following Blunt Chest Trauma.

A 20-year-old woman presented to our trauma center with cardiac rupture after a motor vehicle collision. Our patient was the restrained driver in a high-speed collision. She arrived without external evidence of trauma but in obvious distress with tachycardia, tachypnea, and hypotension. Initial FAST was negative and chest x-ray; however, second FAST was equivocal for pericardial fluid. Computed tomography demonstrated a large hemopericardium, suspicious for cardiac injury. She underwent emergent operative exploration with a median sternotomy. A 1 cm right atrial appendage avulsion was identified and repaired primarily. She recovered uneventfully and was discharged home. Survival of blunt cardiac rupture is extremely rare and can occur in the absence of any external signs of trauma. Surgeons should maintain clinical suspicion for blunt cardiac injury in unstable trauma patients with deceleration injuries. Injury to the low-pressure right atrium likely contributed to her ability to survive transport to a trauma center.