A National Analysis of Traumatic Thoracic Aortic Repair: Does Insurance Status Matter?

BACKGROUND: Traumatic thoracic aortic injuries (TAIs) carry a substantial mortality. Our study aim was to evaluate the impact of insurance status on outcomes in severely injured trauma patients after either thoracic endovascular aortic repair (TEVAR) or open repair using the National Trauma Data Bank Research Data Set (NTDB-RDS). METHODS: The NTDB-RDS was reviewed for outcomes in severely injured patients and TAI repair method (TEVAR vs open). Patients were divided into insured (Medicaid, Medicare, private insurance) and uninsured (self-pay) status groups. Patients were further divided by injury severity score (ISS) of 15-24 and ≥25 to adjust for injury burden. Demographic characteristics and outcome measures were compared. Chi-square, t-test, and analysis of variance were used with significance defined as P < .05. RESULTS: Within the NTDB-RDS, a review of nearly 1 million patients led to 241 that underwent repair for TAI and had insurance status and repair type documented. 88.8% (214/241) of patients were insured, while 11.2% (27/241) of patients were uninsured. There were no significant differences in repair type based on insurance status. For open repair with an ISS ≥25, mortality was significantly higher in the uninsured group compared with insured (55.5% vs 21.9%, P = .001). CONCLUSION: For open repair in patients with TAI and high injury burden, uninsured status was associated with a significant increase in mortality rate compared with insured patients. Future studies should investigate the effect of insurance type on TAI outcomes and causes of higher mortality in uninsured patients.

Factors Affecting Research Productivity of Trauma Surgeons.

This study aimed to identify factors that promote and impede research participation and productivity by Eastern Association for the Surgery of Trauma (EAST) surgeons. In addition, the study aimed to determine what changes can be implemented by surgical departments to improve this research productivity and granting. A 25-question anonymous research survey tool was offered to EAST surgeons. The questions analyzed factors including demographics, career accomplishments, current institution type, educational/research background, perceived barriers to research, and current research productivity, including grants. Chi-square tests were used to analyze significance at P < 0.05. The overall response rate was 26.2 per cent (445/1699). Most respondents reported not having any protected research time (86.3%), and no research resources were provided by their institution (78.7%). Factors that were significantly associated with greater research productivity included protected research time (P < 0.0001), having a mentor (P < 0.001), practicing in a university-affiliated hospital (P < 0.0001), publication(s) before completing residency training (P = 0.02), having institutional resources dedicated to research (P = 0.015), and male gender (P = 0.003). Age, race, marital status, and additional educational qualifications were not associated with statistically significant differences in research productivity in this study (P > 0.05). EAST surgeons are more likely to have scholarly productivity if they are supported with protected time, mentors, nonclinical staff dedicated to research, a history of research before completion of residency, and research resources from their institution. Barriers to research productivity include lack of institutional support, lack of protected research time, and increased regulatory policies.

Factors Affecting Research Productivity of Burn Surgeons: Results from a Survey of American Burn Association Members.

While previous studies have examined factors that affect research productivity for surgeons in general, few studies address research productivity specifically of burn specialists. This study aimed to identify factors that promote and impede research participation and productivity of burn surgeons and help elucidate what changes can be made by departments/divisions to improve the research productivity. A 44-question anonymous research survey tool was administered to burn surgeons who are members of the American Burn Association (ABA). The questions analyzed factors such as demographics, career accomplishments, current institution type, educational background, research background, barriers to conducting research, and current research productivity. Chi-square tests were used to analyze significance at P < .05. Most respondents reported not having any protected research time (71.4%) or resources provided by their institution (84.5%). A majority believed increasing regulatory policies/institutional review board restrictions have negatively impacted productivity (65.1%). Factors associated with positive impact on research productivity included having a mentor, conducting research prior to completing residency, and provision of research resources from the institution such as statistical support, start-up funds, grant writing support, and laboratory space. Age and sex had no statistical impact on research productivity. Burn surgeons are more likely to publish research and to receive grants when they have mentors, a history of research prior to completion of residency, and research resources from their institution. Barriers to research productivity include lack of institutional support, lack of protected research time, and increased regulatory policy.

Distribution of General Surgery Residencies in the United States and Gender Inequality: Are We There Yet?

OBJECTIVE: Surgeons are unevenly distributed across the United States (U.S.), possibly as a result of disproportionately distributed General Surgery (GS) residencies. This study primarily aimed to examine the relationship between the distribution of GS residency positions and population by U.S. region and states. Differences in the distribution by race and gender were also examined. DESIGN: A review of the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) National Residency Matching Program (NRMP) data over 5 years. Categorical Surgery Residency PGY1 positions (SurgPGY1) were categorized into Northeast, Midwest, South, and West regions. SurgPGY1 to population ratios were compared by region. The distribution of SurgPGY1s by race/gender was also compared. PARTICIPANTS: Medical students who match into SurgPGY1 positions through the NRMP. RESULTS: The mean SurgPGY1s per 106 population was 4.18 ± 0.52 for 2018. Most commonly, SurgPGY1s are concentrated in the Northeast (5.79 ± 0.64) then the South (5.12 ± 1.41), then the Midwest (4.22 ± 0.37), and lastly the West (1.91 ± 0.39). NY, MA, and DC had significantly higher SurgPGY1s ratios, with DC topping at 27.05. Four States had no SurgPGY1s (AK, ID, MT, WY), while AR, MS, and UT were under 2 SurgPGY1s/106. From 2014 to 2018, the percent of ACGME positions given to females increased 2.93%, while the AOA positions increased 11.84%. When adjusted for the population the race with the most residencies for their population was Asian (482.42% ACGME, 324.52% AOA). CONCLUSION: There is a significant disproportion in the distribution of GS residencies and not proportional to population, race or gender.

Early versus Late Tracheostomy: Is There an Outcome Difference?

The effect of timing in patients requiring tracheostomy varies in the literature. The purpose of this study was to evaluate the impact of early tracheostomy on outcomes in trauma patients with and without traumatic brain injury (TBI). This study is a four-year review of trauma patients undergoing tracheostomy. Patients were divided into two groups based on TBI/non-TBI. Each group was divided into three subgroups based on tracheostomy timing: zero to three days, four to seven days, and greater than seven days postadmission. TBI patients were stratified by the Glasgow Coma Scale (GCS), and non-TBI patients were stratified by the Injury Severity Score (ISS). The primary outcome was ventilator-free days (VFDs). Significance was defined as P < 0.05. Two hundred eighty-nine trauma patients met the study criteria: 151 had TBI (55.2%) versus 138 (47.8%) non-TBI. There were no significant differences in demographics within and between groups. In TBI patients, statistically significant increases in VFDs were observed with GCS 13 to 15 for tracheostomies performed in four to seven versus greater than seven days (P = 0.005). For GCS <8 and 8 to 12, there were significant increases in VFDs for tracheostomies performed at days 1 to 3 and 4 to 7 versus greater than seven days (P ≪ 0.05 for both). For non-TBI tracheostomies, only ISS ≥ 25 with tracheostomies performed at zero to three days versus greater than seven days was associated with improved VFDs. Early tracheostomies in TBI patients were associated with improved VFDs. In trauma patients with no TBI, early tracheostomy was associated with improved VFDs only in patients with ISS ≥ 25. Future research studies should investigate reasons TBI and non-TBI patients may differ.

Inguinal bladder hernia: A case report and literature review.

INTRODUCTION: Cases of inguinal bladder hernia are rare, with bladder involvement seen in 1-4% of inguinal hernias. The majority of cases are diagnosed intraoperatively, with only 7% of bladder hernias identified prior to surgery. Diagnosis may be challenging as patients are often asymptomatic or have nonspecific symptoms. Surgical repair is currently the standard treatment, and careful surgical planning is necessary to avoid complications including bladder injury. PRESENTATION OF CASE: A 58-year-old man presented to our Emergency Department with 2-day history of progressively worsening left lower quadrant pain, groin bulge, and dysuria. Physical exam revealed an irreducible left inguinal hernia associated with urinary urgency on attempted reduction. Plain CT was ordered and demonstrated inguinal hernia with bladder protrusion into the left scrotum. The patient underwent open surgical reduction and hernia repair and made a quick postoperative recovery without complications. DISCUSSION: Inguinal bladder hernia most often presents in older, obese males and clinicians should have a high index of suspicion when assessing patients with inguinal hernia. Preoperative diagnosis based on history, physical, and radiologic imaging allow for careful surgical planning and prevention of severe complications including bladder injury and leakage. CONCLUSION: We present a case report of inguinal bladder hernia in a middle-aged man that presented as left lower quadrant pain, groin pain, and dysuria. Diagnosis was confirmed preoperatively with radiographic imaging. The hernia was surgically reduced and the defect repaired without complications.