Utility of Repetitive Transcranial Magnetic Stimulation for Chronic Daily Headache Prophylaxis: A Systematic Review and Meta-Analysis.

PURPOSE OF REVIEW: Management of chronic daily headaches (CDH) remains challenging due to the limited efficacy of standard prophylactic pharmacological measures. Several studies have reported that repetitive transcranial magnetic stimulation (rTMS) can effectively treat chronic headaches. The objective was to determine the utility of rTMS for immediate post-treatment and sustained CDH prophylaxis. RECENT FINDINGS: All procedures were conducted per PRISMA guidelines. PubMed, Scopus, Web of Science, and ProQuest databases were searched for controlled clinical trials that have tested the efficacy of rTMS on populations with CDH. DerSimonian-Laird random-effects meta-analyses were performed using the 'meta' package in R to examine the post- vs. pre-rTMS changes in standardized headache intensity and frequency compared to sham-control conditions. Thirteen trials were included with a combined study population of N = 538 patients with CDH (rTMS, N = 284; Sham, N = 254). Patients exposed to rTMS had significantly reduced standardized CDH intensity and frequency in the immediate post-treatment period (Hedges' g = -1.16 [-1.89, -0.43], p = 0.002 and Δ = -5.07 [-10.05, -0.11], p = 0.045 respectively). However, these effects were sustained marginally in the follow-up period (Hedges' g = -0.43 [-0.76, -0.09], p = 0.012 and Δ = -3.33 [-5.52, -1.14], p = 0.003). Significant between-study heterogeneity was observed, at least partially driven by variations in rTMS protocols. Despite the observed clinically meaningful and statistically significant benefits in the immediate post-treatment period, the prophylactic effects of rTMS on CDH do not seem to sustain with discontinuation. Thus, the cost-effectiveness of the routine use of rTMS for CDH prophylaxis remains questionable. REGISTRATION: Protocol preregistered in PROSPERO International Prospective Register of Systematic Reviews (CRD42021250100).

Using the Social Vulnerability Index to Analyze Statewide Health Disparities in Cholecystectomy.

INTRODUCTION: Addressing the effects of social determinants of health in surgery has become a national priority. We evaluated the utility of the Social Vulnerability Index (SVI) in determining the likelihood of receiving cholecystectomy for cholecystitis in Texas. METHODS: A retrospective study of adults with cholecystitis in the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Data Public Use Data File from 2016 to 2019. Patients were stratified into SVI quartiles, with the lowest quartile as low vulnerability, the middle two as average vulnerability, and the highest as high vulnerability. The relative risk (RR) of undergoing surgery was calculated using average vulnerability as the reference category and subgroup sensitivity analyses. RESULTS: A total of 67,548 cases were assessed, of which 48,603 (72.0%) had surgery. Compared with the average SVI groups, the low vulnerability groups were 21% more likely to undergo cholecystectomy (RR = 1.21, 95% confidence interval [CI] 1.18-1.24), whereas the high vulnerability groups were 9% less likely to undergo cholecystectomy (RR = 0.91, 95% CI 0.88-0.93). The adjusted model showed similar results (RR = 1.05, 95% CI 1.04-1.06 and RR = 0.97, 95% CI 0.96-0.99, for low and high vulnerability groups, respectively). These results remained significant after stratifying for age, sex, ethnicity, and insurance status. However, the differences between low, average, and high vulnerability groups diminished in rural settings, with lower surgery rates in all groups. CONCLUSIONS: Patients with higher SVI were less likely to receive an elective cholecystectomy. SVI is an effective method of identifying social determinants impacting access to and receipt of surgical care.

Association of social vulnerability with receipt of hernia repair in Texas.

BACKGROUND: The effect of social health determinants on hernia surgery receipt is unclear. We aimed to assess the association of the social vulnerability index with the likelihood of undergoing elective and emergency hernia repair in Texas. METHODS: This is a retrospective cohort analysis of the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Public Use Data File from 2016 to 2019. Patients ≥18 years old with inguinal or umbilical hernia were included. Social vulnerability index and urban/rural status were merged with the database at the county level. Patients were stratified based on social vulnerability index quartiles, with the lowest quartile (Q1) designated as low vulnerability, Q2 and Q3 as average, and Q4 as high vulnerability. Wilcoxon rank sum, t test, and χ2 analysis were used, as appropriate. The relative risk of undergoing surgery was calculated with subgroup sensitivity analysis. RESULTS: Of 234,843 patients assessed, 148,139 (63.1%) underwent surgery. Compared to patients with an average social vulnerability index, the low social vulnerability index group was 36% more likely to receive surgery (relative risk: 1.36, 95% CI 1.34-1.37), whereas the high social vulnerability index group was 14% less likely to receive surgery (relative risk: 0.86, 95% CI 0.85-0.86). This remained significant after stratifying for age, sex, insurance status, ethnicity, and urban/rural status (P < .05). For emergency admissions, there was no difference in receipt of surgery by social vulnerability index. CONCLUSION: Vulnerable patients are less likely to undergo elective surgical hernia repair, even after adjusting for demographics, insurance, and urbanicity. The social vulnerability index may be a useful indicator of social determinants of health barriers to hernia repair.

Baseline glucose levels moderate the association between burn-related mortality inpatients with obesity.

BACKGROUND: Differing findings concerning outcomes for burn patients with obesity indicate additional factors at play. One possible explanation could lie in determining metabolically healthy versus unhealthy obesity, which necessitates further study. METHODS: A retrospective study was conducted using the Cerner Health Facts® Database. Deidentified patient data from 2014 to 2018 with second or third-degree burn injuries were retrieved. A moderator analysis was conducted to determine if the association between increased body mass index (BMI) and mortality is moderated by baseline glucose level, a surrogate marker associated with metabolically unhealthy obesity. RESULTS: The study included 4682 adult burn patients. BMI alone was not associated with higher mortality (ß = 0.106, p = 0.331). Moderation analysis revealed that baseline glucose level significantly modulated the impact of BMI on burn-related obesity; patients with higher BMI and higher baseline blood glucose levels had higher mortality than those with lower baseline blood glucose levels (ß = 0.277, p = 0.009). These results remained unchanged after adjusting for additional covariates (ß = 0.285, p = 0.025) and inthe sensitivity analysis. CONCLUSIONS: Increased baseline glucose levels indicate increased mortality in obese patients with burn injuries, emphasizing the differentiation between metabolically unhealthy versus healthy obesity.

Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study.

BACKGROUND: Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury. METHODS: Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R. RESULTS: AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged. CONCLUSION: BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.

Impact of Access to Breast Care For West Texas Program on Early Detection and Regional Breast Cancer Mortality.

INTRODUCTION: This study aimed to assess whether the Access to Breast Care for West Texas (ABC4WT) program impacted regional breast cancer detection and mortality in the Texas Council of Governments (COG)1 region. METHODS: Interrupted time series analyses were utilized to evaluate the impact of the intervention. Spearman's rank correlation and cross-orrelation analyses were performed to assess the relationship between the total number of screenings and (i) the total number of breast cancer detected and (ii) the proportion of early-stage cancer detected and the (pre-whitened) residuals. A three-way interaction model compared pre-and post-intervention mortality in COG 1 with the COG 9 region (control). RESULTS: Increased screening rate was associated with increased breast and early-stage cancer incidences (P = .001 and P = .002, respectively). There were significant positive cross-correlations between the total number of screenings and the total number of breast cancer detected (r = .996) and the proportion of early-stage cancer detected (r = .709) without a lag even after pre-whitening. Univariate analysis showed that regional mortality decreased with time (P < .001) and after intervention (P = .001). Multivariate analysis did not show any significant difference in time (P = .594), intervention (P = .453), and time and intervention interaction (P = .273). The three-way interaction model showed no difference in the baseline mortality and pre-intervention trend difference in COG 1 and COG 9 regions. However, there was a significant pre-post intervention trend difference in mortality COG 1 compared to the COG 9 region (P = .041). CONCLUSION: Implementing the ABC4WT program was associated with the early detection of breast cancer and reducing regional mortality in the COG 1 region.

Comprehensive Profiling of Cancer-Associated Cells in the Blood of Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy to Predict Pathological Complete Response.

Neoadjuvant chemotherapy (NAC) can affect pathological complete response (pCR) in breast cancers; the resection that follows identifies patients with residual disease who are then offered second-line therapies. Circulating tumor cells (CTCs) and cancer-associated macrophage-like cells (CAMLs) in the blood can be used as potential biomarkers for predicting pCR before resection. CTCs are of epithelial origin that undergo epithelial-to-mesenchymal transition to become more motile and invasive, thereby leading to invasive mesenchymal cells that seed in distant organs, causing metastasis. Additionally, CAMLs in the blood of cancer patients are reported to either engulf or aid the transport of cancer cells to distant organs. To study these rare cancer-associated cells, we conducted a preliminary study where we collected blood from patients treated with NAC after obtaining their written and informed consent. Blood was collected before, during, and after NAC, and Labyrinth microfluidic technology was used to isolate CTCs and CAMLs. Demographic, tumor marker, and treatment response data were collected. Non-parametric tests were used to compare pCR and non-pCR groups. Univariate and multivariate models were used where CTCs and CAMLs were analyzed for predicting pCR. Sixty-three samples from 21 patients were analyzed. The median(IQR) pre-NAC total and mesenchymal CTC count/5 mL was lower in the pCR vs. non-pCR group [1(3.5) vs. 5(5.75); p = 0.096], [0 vs. 2.5(7.5); p = 0.084], respectively. The median(IQR) post-NAC CAML count/5 mL was higher in the pCR vs. non-pCR group [15(6) vs. 6(4.5); p = 0.004]. The pCR group was more likely to have >10 CAMLs post-NAC vs. non-pCR group [7(100%) vs. 3(21.4%); p = 0.001]. In a multivariate logistic regression model predicting pCR, CAML count was positively associated with the log-odds of pCR [OR = 1.49(1.01, 2.18); p = 0.041], while CTCs showed a negative trend [Odds Ratio (OR) = 0.44(0.18, 1.06); p = 0.068]. In conclusion, increased CAMLs in circulation after treatment combined with lowered CTCs was associated with pCR.

Central Executive and Default Mode Networks: An Appraisal of Executive Function and Social Skill Brain-Behavior Correlates in Youth with Autism Spectrum Disorder.

Atypical connectivity patterns have been observed for individuals with autism spectrum disorders (ASD), particularly across the triple-network model. The current study investigated brain-behavior relationships in the context of social skills and executive function profiles for ASD youth. We calculated connectivity measures from diffusion tensor imaging using Bayesian estimation and probabilistic tractography. We replicated prior structural equation modeling of behavioral measures with total default mode network (DMN) connectivity to include comparisons with central executive network (CEN) connectivity and CEN-DMN connectivity. Increased within-CEN connectivity was related to metacognitive strengths. Our findings indicate behavior regulation difficulties in youth with ASD may be attributable to impaired connectivity between the CEN and DMN and social skill difficulties may be exacerbated by impaired within-DMN connectivity.

Utility of Cell Saver in Trauma Compared to Cardiac Surgery.

While reperfusion of autologous blood using the Cellsaver (CS) device is routine in cardiothoracic surgery, there is a paucity of evidence-based literature regarding its use in trauma. Utility of CS was compared in these two distinct populations at a Level 1 trauma center from 2017 to 2022. CS was successfully used in 97% and 74% of cardiac and trauma cases, respectively. The proportion of blood requirements provided by CS, compared to allogenic transfusion, was also significantly higher in cardiac surgery. However, there was still net benefit for CS in trauma surgery, with median salvaged transfusion volume of one unit, in both general & orthopedic trauma. Therefore, in centers where the cost of setting up CS, both in terms of equipment and personnel, is less than the cost of one unit of blood from blood bank, use of CS in trauma operations should be considered.

Impact of elevated body mass index on burn injury-associated mortality in a representative US sample.

BACKGROUND: The impact of obesity on burn-related mortality is inconsistent and incongruent; despite being a risk factor for numerous comorbidities that would be expected to increase complications and worsen outcomes, there is evidence of a survival advantage for patients with high body mass index-the so-called obesity paradox. We used a national data set to explore further the relationship between body mass index and burn-related mortality. METHODS: Deidentified data from patients with second and third-degree burns between 2014 and 2018 were obtained from the Cerner Health Facts Database. Univariate and multivariate regression models were created to identify potential factors related to burn-related mortality. A restricted cubic spline model was built to assess the nonlinear association between body mass index and burn-related mortality. All statistical analyses were conducted using R (R Foundation for Statistical Computing). RESULTS: The study included 9,405 adult burn patients. Univariate and multivariate analyses revealed that age (odds ratio = 2.189 [1.771, 2.706], P < .001), total burn surface area (odds ratio = 1.824 [1.605, 2.074], P < .001), full-thickness burns (odds ratio = 1.992 [1.322, 3.001], P < .001), and comorbidities (odds ratio = 2.03 [1.367, 3.014], P < .001) were associated with increased mortality. Sensitivity analysis showed similar results. However, a restricted cubic spline indicated a U-shaped relation between body mass index and burn-related mortality. The nadir of body mass index was 28.92 kg/m2, with the lowest mortality. This association persisted even after controlling for age, total burn surface area, full-thickness burns, and comorbidities, which all remained significant. CONCLUSION: This study confirms a U-shaped association between body mass index and burn-related mortality along with age, total burn surface area, full-thickness burns, and comorbidities as risk factors.

The effectiveness of botulinum toxin for chronic tension-type headache prophylaxis: A systematic review and meta-analysis.

BACKGROUND: A systematic and meta-analysis was conducted to examine the evidence of the effects of botulinum toxin A on chronic tension-type headache. METHODS: Cochrane, Embase, Ovid, ProQuest, PubMed, Scopus, Web-of-Science databases, and ClinicallTrials.gov registry were systematically searched for studies examining the effects of botulinum toxin A on tension-type headaches. The records were screened by two independent reviewers using pre-determined eligibility criteria. DerSimonian Liard random-effects meta-analyses were performed using the 'meta' package (5.2-0) in R (4.2.0). Risk of bias and quality of evidence were assessed using the Cochrane Collaboration's Tool RoB 2 and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Clinical significance was determined using pre-defined minimal clinically important differences. RESULTS: Eleven controlled trials were included (390 botulinum toxin A, 297 controls). Botulinum toxin A was associated with significant improvements in standardized headache intensity (-0.502 standard deviations [-0.945, -0.058]), headache frequency (-2.830 days/month [-4.082, -1.578]), daily headache duration (-0.965 [-1.860, -0.069]) and the frequency of acute pain medication use (-2.200 days/month [-3.485, -0.915]) vs controls. Botulinum toxin A-associated improvements exceeded minimal clinically important differences for headache intensity, frequency, and acute pain medication use. A 79% (28%, 150%) greater response rate was observed for botulinum toxin A vs controls in improving chronic tension-type headache. Treatment of eight chronic tension-type headache patients was sufficient to elicit a therapeutic response in one patient. CONCLUSIONS: Corroborating the current mechanistic evidence, our meta-analysis supports the utility of botulinum toxin A for managing chronic tension-type headaches. However, due to limitations in the quality of evidence, adequately-powered high-quality controlled trials examining the effects of Botulinum toxin A on chronic tension-type headache are warranted. REGISTRATION: Protocol preregistered in PROSPERO International Prospective Register of Systematic Reviews (CRD42020178616).

Association Between Autism Spectrum Disorders and Cardiometabolic Diseases: A Systematic Review and Meta-analysis.

Importance: Although the increased risk of obesity among individuals with autism has been well established, evidence on the association between autism, cardiometabolic disorders, and obesity remains inconclusive. Objective: To examine the association between autism spectrum disorders and cardiometabolic diseases in a systematic review and meta-analysis. Data Sources: PubMed, Scopus, Web of Science, ProQuest, Embase, and Ovid databases were searched from inception through July 31, 2022, without restrictions on date of publication or language. Study Selection: Observational or baseline data of interventional studies reporting the prevalence of cardiometabolic risk factors (ie, diabetes, hypertension, dyslipidemia, atherosclerotic macrovascular disease) among children and/or adults with autism and matched with participants without autism were included. Data Extraction and Synthesis: Screening, data extraction, and quality assessment were performed independently by at least 2 researchers. DerSimonian-Laird random-effects meta-analyses were performed using the meta package in R. Main Outcomes and Measures: Relative risks (RRs) of diabetes, hypertension, dyslipidemia, and atherosclerotic macrovascular disease among individuals with autism were the primary outcomes. Secondary outcomes included the RR of type 1 and type 2 diabetes, heart disease, stroke, and peripheral vascular disease. Results: A total of 34 studies were evaluated and included 276 173 participants with autism and 7 733 306 participants without autism (mean [range] age, 31.2 [3.8-72.8] years; pooled proportion [range] of female individuals, 47% [0-66%]). Autism was associated with greater risks of developing diabetes overall (RR, 1.57; 95% CI, 1.23-2.01; 20 studies), type 1 diabetes (RR, 1.64; 95% CI, 1.06-2.54; 6 studies), and type 2 diabetes (RR, 2.47; 95% CI, 1.30-4.70; 3 studies). Autism was also associated with increased risks of dyslipidemia (RR, 1.69; 95% CI, 1.20-2.40; 7 studies) and heart disease (RR, 1.46; 95% CI, 1.42-1.50; 3 studies). Yet, there was no significantly associated increased risk of hypertension and stroke with autism (RR, 1.22; 95% CI, 0.98-1.52; 12 studies; and RR, 1.19; 95% CI, 0.63-2.24; 4 studies, respectively). Meta-regression analyses revealed that children with autism were at a greater associated risk of developing diabetes and hypertension compared with adults. High between-study heterogeneity was a concern for several meta-analyses. Conclusions and Relevance: Results suggest that the associated increased risk of cardiometabolic diseases should prompt clinicians to vigilantly monitor individuals with autism for potential contributors, signs of cardiometabolic disease, and their complications.

Improved Outcomes in Treating Acute Biliary Disorders With a Shift-Based Acute Care Surgery Model.

BACKGROUND: As Acute Care Surgery and shift-based models increase in popularity, there is evidence of better outcomes for many types of emergency general surgery patients. We explored the difference in outcomes for patients with acute biliary disorders, treated by either Acute Care Surgery (ACS) model or traditional call model (TRAD) during the same period. METHODS: Retrospective review of patients undergoing laparoscopic cholecystectomy for acute biliary disease 2017-2018. Demographics, clinical presentation, operative details, and outcomes were compared. RESULTS: Demographics, clinical presentation, and complication rates were similar between groups. Time from surgical consult to operating room (Δ = -15.34 hours [-24.57, -6.12], P = .001), length of stay (Δ = -1.4 days [-2.45, -.35], P = .009), and total charges were significantly decreased in ACS group compared to TRAD (Δ$2797.76 [-4883.12, -712.41], P = .009). CONCLUSIONS: Acute biliary disease can be managed successfully in an ACS shift-based model with reduced overall hospital charges and equivalent outcomes.

Predicting Outcomes in Trauma Patients With Cirrhosis Using Model for End-Stage Liver Disease Score: A Retrospective Study.

BACKGROUND: Liver cirrhosis is associated with increased mortality in trauma victims. We stratified the impact of cirrhosis on trauma mortality by Model for End-stage Liver Disease (MELD) score. METHODS: Trauma center database was accessed for patients with established diagnosis of cirrhosis presenting 2014 - 2018, matched to control patients without cirrhosis in a 2:1 ratio by age, sex, and TRISS. Primary outcome was mortality, secondary outcomes were length of stay, intensive care unit days, and ventilator dependent days. RESULTS: Cirrhosis was present in 182 (1.5%) trauma patients. Mortality difference between 12 (7%) deaths in cirrhosis cohort versus 14 (4%) in control was not statistically significant (p = 0.38). No difference was found in secondary outcomes. Categorization of cirrhosis severity by MELD score range (MELD 6-7, 8-10, 11-14, 15-20, 21-30) showed a 1.9 fold increase in the odds of mortality for every increase in MELD score category (OR = 1.91, p = 0.03, 95% CI = 1.08 - 3.37). CONCLUSION: Mortality effects of cirrhosis in trauma patients can be estimated using MELD score.

Should We Perform Incidental Appendectomy in Trauma Patients Undergoing Laparotomy?

Incidental appendectomy (IA) is sometimes performed in patients undergoing abdominal operations to prevent subsequent development of appendicitis. Patients who undergo laparotomy for major abdominal trauma are at high risk of developing dense adhesions, increasing the risk of future operations. Therefore, there is a potential benefit to IA for patients undergoing trauma laparotomy. We performed a retrospective review of patients who underwent IA during laparotomy for abdominal trauma at a Level 1 trauma center between January 2010, and June 2020. Twenty-three patients underwent IA; they tended to be young (33.7 ± 18.9 years) and male (87%) with 12 penetrating and 11 blunt injuries. Regarding indications, 13 had no documented intra-operative abnormalities of the appendix, 6 patients had a fecalith, and 3 had trauma to the appendix. One patient's appendix was adhered to the peritoneum and one patient had unusual anatomic location. Only one patient developed an appendiceal stump leak after IA.

Comparing Outcomes of Sub-Total Cholecystectomy Versus Open Cholecystectomy as Bailout Procedures for the Difficult Gallbladder.

BACKGROUND: Although laparoscopic cholecystectomy is one of the most common operations performed, there is no consensus on the best surgical approach when inflammation obscures hepatocystic anatomy in severe cholecystitis. Traditionally, this situation triggered conversion to open cholecystectomy (COC); however, in recent decades, alternative approaches have been described. We compared outcomes of bailout procedures for severe cholecystitis, primarily focusing on COC versus laparoscopic subtotal cholecystectomy (LSTC). STUDY DESIGN: Retrospective review comparing outcomes of intended laparoscopic cholecystectomy cases that were converted to bailout procedures between 2015-2020 at a single institution. Bailout procedures were categorized into LSTC and COC groups. Demographics, clinical presentation, time to surgery, operative indications, operative duration, and post-operative outcomes were compared using independent sample t-tests with Welch-Satterthwaite correction or Wilcoxon rank-sum tests (continuous variables) or Fisher's exact/χ2 tests. A P-value of less than .05 was considered significant. RESULTS: Final analysis included 158 subjects: 55 LSTC and 99 COC. Patient demographics and clinical presentations were similar between groups. LSTC had shorter operative time, fewer ICU admissions, and shorter length of stay than COC (P < .05). There were 9 (9.2%) cases of ileus, 4 (4.0%) cases of post-operative bleeding, and 2 (2.0%) cases of bile duct injury in COC. There was 1 (1.8%) case of ileus, 1 (1.8%) case of post-operative bleeding, and no bile duct injury in LSTC. CONCLUSION: LSTC was associated with fewer complications than COC, which had higher rates of biliary injury, bleeding, ileus, ICU admission, and longer hospital stay.

Regional Variations in Microbiology and Outcomes of Necrotizing Soft Tissue Infections: A Systematic Review and Meta-Analysis.

Background: Frequency, microbiology, and outcomes of necrotizing soft tissue infections (NSTIs) could vary across the United States because of differences in locoregional and environmental factors. We synthesized the literature from across the regions of the United States on NSTIs in a systematic review/meta-analysis. Methods: PubMed, ProQuest, Scopus, and Web of Science databases were systematically searched and screened. DerSimonian-Laird random-effects meta-analyses were performed using 'meta' package in R to determine pooled prevalences. Meta-regression analyses examined moderator effects of risk factors. Results: Twenty-seven studies (2,242 total patients) were included. Pooled prevalences of polymicrobial and monomicrobial infections were 52.2% and 39.9%, respectively. The prevalence of monomicrobial NSTIs increased over the last two decades (p = 0.018), whereas polymicrobial infections declined (p = 0.003). Meta-regression analysis showed that most polymicrobial NSTIs were Fournier gangrene (p < 0.001), whereas monomicrobial NSTIs mostly affected extremities (p < 0.001). Staphylococcus aureus was the most common organism isolated (predominantly in the South), followed by Bacteroides spp. (predominately in the East) and Streptococcus pyogenes. Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 11.9% of NSTIs, mainly in the South. The overall mortality rate was 17.8% and declined over last two decades (p < 0.001), with the lowest rate reported in the last decade at 13% without any regional differences. Conclusions: Advancement in the management of NSTIs may have contributed to the observed decline in NSTI-related mortality in the United States. However, the proportion of monomicrobial NSTIs seems to be increasing, possibly because of increased comorbidities affecting extremities. Causative organisms varied by region. Multi-center observational studies are warranted to confirm our observations.

Comparing outcomes between patients transferred from a critical access hospital versus directly from scene to a level 1 trauma center.

OBJECTIVES: The aim of this retrospective study was to compare the outcomes of trauma patients directly transported to a level I trauma center (SCENE) versus those who were stabilized at a critical access hospital (CAH) and subsequently transferred. METHODS: Patients were grouped based on their transfer status, interventions performed at CAH and outcomes. Google Maps was used to calculate the distances from the location of injury (LOI). Each transfer group data was analyzed separately to examine associations of different factors on the outcomes. Outcomes were compared using univariate and multivariate analyses and propensity score matching analysis. RESULTS: There were 262 patients in SCENE and 684 in CAH. Compared to SCENE, CAH had higher rates of blunt injury and a greater distance from LOI, whereas lower ISS score and length of stay (LOS) (p < 0.05). The majority of CAH group survived compared to SCENE (p = 0.007). For both groups, baseline factors (e.g., age) were associated with outcomes (p < 0.05). Interestingly, longer LOS in the CAH was associated with an increase in survival (p = 0.009), whereas an increased number of CT/MRI performed was associated with increased LOS (p < 0.05)., and an increased number of procedures was associated with longer LOS and ICU stay (p < 0.05). After matching, the two groups had no significant differences in survival, LOS, or ICU stay (p > 0.05). CONCLUSION: Equivalent overall clinical outcomes were seen in both groups, suggesting that existing trauma system protocols in the West Texas region are functioning well to select appropriate patients for each transfer modality. LEVEL OF EVIDENCE III: Retrospective Analysis.

Effects of consumption of coconut oil or coconut on glycemic control and insulin sensitivity: A systematic review and meta-analysis of interventional trials.

BACKGROUND AND AIMS: The often purported claim that coconut fat is beneficial for cardiovascular health and was disputed in several recent meta-analyses. However, the evidence on the effects of coconut fat intake on glycemic control remains equivocal. We conducted a systematic review and meta-analysis in accordance with the PRISMA guidelines to determine the effects of dietary coconut fats on markers of acute and long-term glycemic control. METHODS AND RESULTS: PubMed, Scopus, ProQuest, and Web-of-Science databases were searched and the records were screened by three independent reviewers to identify interventional studies examining acute and long-term (i.e., >10 days) effects of coconut fat on glycemic control. DerSimonian-Laird random-effects meta-analyses were performed using the meta-package in R (4.0.2). Seven interventional studies on acute effects and 11 interventional studies on long-term effects of coconut fat were included. Meals with coconut fat acutely increased the incremental area under the curve (AUC) of glucose (p = 0.046) and decreased the incremental AUC of insulin (p = 0.037) vs. control meals. Long-term coconut fat intake increased HOMA-IR (p = 0.049), but did not significantly affect fasting glucose, insulin, or HOMA-ß vs. control meals. CONCLUSIONS: Coconut fat in meals seems to be associated with a diminished postprandial insulin response, resulting in a subtle increase in the postprandial glycemic response. Long-term intake of coconut fat seems to increase insulin resistance, yet does not seem to be beneficial for long-term glycemic control. Thus, our results disprove the popular claim that coconut fat improves glycemic control. REGISTRATION: PROSPERO registry (CRD42020183450).