Race, Insurance, and Socioeconomic Influences on Outcomes Following Roux-En-Y Gastric Bypass.

The effectiveness of Roux-en-Y gastric bypass (RYGB) might be shadowed by disparities in outcomes related to patient race and insurance type. We determine the influence of patient race/ethnicity and insurance types on complications following RYGB. We performed a retrospective analysis using data sourced from the National Inpatient Sample Database (2010 to 2019). A multivariate analysis was employed to determine the relationship between patient race/ethnicity and insurance type on RYGB complications. The analysis determined the interaction between race/ethnicity and insurance type on RYGB outcomes. We analyzed 277714 patients who underwent RYGB. Most of these patients were White (64.5%) and female (77.3%), with a median age of 46 years (IQR 36-55). Medicaid beneficiaries displayed less favorable outcomes than those under private insurance: Extended hospital stay (OR = 1.68; 95% CI 1.58-1.78), GIT Leak (OR = 1.83; 95% CI 1.35-2.47), postoperative wound infection (OR = 1.88; 95% CI 1.38-2.55), and in-hospital mortality (OR = 2.74; 95% CI 1.90-3.95).

Adherence Rate to Alliance for Clinical Trials in Oncology Z0011 Trial Based on Breast Cancer Subtype.

BACKGROUND: The American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011 or Z11) trial demonstrated no survival advantage with completion axillary lymph node dissection (ALND) for patients with T1-2 breast cancer, 1 to 2 positive SLNs who received adjuvant chemoradiation therapy. More than 70% of the cohort had estrogen receptor (ER)+ tumors. There is paucity of data on the adherence rate to Z11, as well as a dearth of data on the applicability of Z11 for the different subtypes. We conducted a large hospital-based study to evaluate the adherence rate to Z11 based on subtypes. STUDY DESIGN: The National Cancer Database was queried to evaluate 33,859 patients diagnosed with T1-2, N1, and M0 breast cancer treated with lumpectomy with negative margins, and adjuvant chemoradiation therapy between 2012 and 2018. Patients were classified into 3 groups: (1) ER+/HER2-, (2) ER-/HER2-, and (3) HER2+ regardless of ER status. The revised Scope of the Regional Lymph Node Surgery 2012 was used to classify patients into those who underwent an SLN or ALND. Differences in use of ALND by subtypes were compared. The Kaplan-Meier method and log-rank test were used to compare overall survival (OS). A p value of <0.05 was considered statistically significant. RESULTS: For ER+/human epidermal growth factor receptor 2 (HER2)-, ER-/HER2-, and HER2+ tumors, the rate of ALND was 43.6%, 50.2%, and 47.8%, respectively. The 5-year OS for SLN and ALND for the entire cohort was 94.0% and 93.1% (p = 0.0004); for ER+/HER2-, it was 95.4% and 94.7% (p = 0.04); for ER-/HER2-, it was 84.1% and 84.3% (p = 0.41); for HER2+, it was 94.2% and 93.2% (p = 0.20). Multivariable cox proportional hazard regression analysis demonstrated no significant survival differences between SLN and ALND (p = 0.776). CONCLUSIONS: Z11 is applicable for women with early N1 disease, regardless of subtypes. ALND did not confer a survival advantage over SLN. Despite this, up to 50% of patients who fit Z11 criteria continue to undergo ALND.

Early Cholecystectomy in Patients with Sickle Cell Disease with Uncomplicated Cholelithiasis Is Associated with Better Outcomes.

BACKGROUND: Up to 85% of patients with sickle cell disease (SCD) will develop gallstones by their third decade. Cholecystectomy is the most commonly performed procedure in these patients. Cholecystectomy is recommended for patients with SCD with symptomatic cholelithiasis and leads to lower morbidity. No contemporary large studies have evaluated this recommendation or associated clinical outcomes. This study evaluates clinical outcomes after cholecystectomy in patients with SCD and cholelithiasis with specific advanced clinical presentations. STUDY DESIGN: The Nationwide Inpatient Sample was queried for patients with SCD and gallbladder disease between 2006 and 2015. Patients were divided into groups based on their disease presentation, including uncomplicated cholelithiasis, acute and chronic cholecystitis, and gallstone pancreatitis. Clinical outcomes associated with disease presentation were analyzed. Statistical analysis was performed using the Student's t -test, chi-square test, ANOVA, and logistic regression. RESULTS: There were 6,662 patients with SCD who presented with cholelithiasis. Median age was 20 (interquartile range 16 to 34) years and 54% were female patients. Cholecystectomy was performed in 1,779 patients with SCD with the most common indication being chronic cholecystitis (44%), followed by uncomplicated cholelithiasis (27%), acute cholecystitis (21%), and choledocholithiasis or gallstone pancreatitis (8%). On multivariable regression, advanced clinical presentation was the strongest predictor of perioperative vaso-occlusive crisis, which was the most common complication. Patients undergoing cholecystectomy for uncomplicated cholelithiasis were at lower risk than those with acute cholecystitis (odds ratio [OR] 2.37; 95% CI 1.64 to 3.41), chronic cholecystitis (OR 1.74; 95% CI 1.26 to 2.4), and choledocholithiasis or gallstone pancreatitis (OR 2.24; 95% CI 1.41 to 3.57). CONCLUSIONS: Seventy-three percent of patients with SCD have advanced clinical presentation at the time of their cholecystectomy. After cholecystectomy, perioperative vaso-occlusive events were significantly increased in patients with advanced clinical presentation. These data support screening abdominal ultrasounds and early cholecystectomy for cholelithiasis in patients with SCD.

Analysis of the National Resident Matching Program for Surgical Critical Care Training in the United States: 2008-2022.

BACKGROUND: Few studies have assessed the pipeline for surgical intensivists despite projected shortages in the United States' critical care workforce. We had 3 primary objectives in analyzing the Surgical Critical Care Match: (1) understand growth in the number of applicants relative to training positions; (2) compare match rates for United States Allopathic Graduates versus non-United States Allopathic Graduates; and (3) analyze the number of unfilled training positions over time. METHODS: This was a national cohort study of Surgical Critical Care Match applicants (2008-2022). Annual match rates and applicant-to-training position ratios were calculated. Cochrane-Armitage tests elucidated temporal trends during the study period. RESULTS: There was a greater increase in the number of annual applicants (276% increase) relative to training positions (128% increase) during the study period (P < .001). The applicant-to-training position ratio increased (0.5-0.9, P < .001). Annual match rates increased for both United States Allopathic (92%-97%, P = .015) and non-United States Allopathic (81%-96%, P < .001) Graduates. Match rates for United States Allopathic Graduates exceeded those for non-United States Allopathic Graduates (P < .05) but were similar from 2020 to 2022 (P > .05). The percentage of applicants that matched at their top fellowship choice decreased from 69%-50% (P < .001). From 2008 to 2022, fewer available training positions went unfilled (52%-13%, P < .001). CONCLUSION: The pipeline for surgical intensivists in the United States appears to be increasing along with rising interest in Surgical Critical Care training. Future research is needed to understand disparities in match rates by applicant and fellowship program characteristics.

Mental health symptoms are comparable in patients hospitalized with acute illness and patients hospitalized with injury.

BACKGROUND: High rates of mental health symptoms such as depression, anxiety, and posttraumatic stress disorder (PTSD) have been found in patients hospitalized with traumatic injuries, but little is known about these problems in patients hospitalized with acute illnesses. A similarly high prevalence of mental health problems in patients hospitalized with acute illness would have significant public health implications because acute illness and injury are both common, and mental health problems of depression, anxiety, and PTSD are highly debilitating. METHODS AND FINDINGS: In patients admitted after emergency care for Acute Illness (N = 656) or Injury (N = 661) to three hospitals across the United States, symptoms of depression, anxiety, and posttraumatic stress were compared acutely (Acute Stress Disorder) and two months post-admission (PTSD). Patients were ethnically/racially diverse and 54% female. No differences were found between the Acute Illness and Injury groups in levels of any symptoms acutely or two months post-admission. At two months post-admission, at least one symptom type was elevated for 37% of the Acute Illness group and 39% of the Injury group. Within racial/ethnic groups, PTSD symptoms were higher in Black patients with injuries than for Black patients with acute illness. A disproportionate number of Black patients had been assaulted. CONCLUSIONS: This study found comparable levels of mental health sequelae in patients hospitalized after emergency care for acute illness as in patients hospitalized after emergency care for injury. Findings of significantly higher symptoms and interpersonal violence injuries in Black patients with injury suggest that there may be important and actionable differences in mental health sequelae across ethnic/racial identities and/or mechanisms of injury or illness. Routine screening for mental health risk for all patients admitted after emergency care could foster preventive care and reduce ethnic/racial disparities in mental health responses to acute illness or injury.

The Distressed Communities Index: A Measure of Community-Level Economic Deprivation and Rate of Firearm Injuries in Maryland.

BACKGROUND: This study aimed to investigate the relationship between community-level economic deprivation, as measured by the Distressed Communities Index (DCI) and ED visits on account of firearm injuries (assaults and unintentional). METHODS: A retrospective analysis was conducted using the Maryland State Emergency Department Databases (SEDD) from January 2019 to December 2020 to explore the association between the DCI and ED visits because of firearm injuries (assaults and unintentional). The DCI utilizes 7 variables, based on zip codes, generating 5 levels of socioeconomic distress (prosperous, comfortable, mid-tier, at-risk, and distressed). In a multivariate analysis, we adjusted for age, sex, mental conditions, alcohol addiction, substance abuse, smoking, race/ethnicity, insurance type, and median income. RESULTS: Of the 2725 ED visits for firearm injuries, 84.5% were Black and 88.5% male. The median age was 27 (21-35) years, and the mortality rate was 17.7%. A statistically significant association was found between economic deprivation and ED visits for firearm injuries. Compared to prosperous communities, the odds ratios (ORs) were comfortable (OR = 1.33, 95% CI 1.04-1.71, P = .03), mid-tier (OR = 1.69, 95% CI 1.33-2.15, P < .001), at-risk (OR = 1.53, 95% CI 1.17-1.99, P < .001), and distressed (OR = 2.65, 95% CI 2.11-3.33, P < .001). DISCUSSION: The study highlights the significant association between community-level economic deprivation, as measured by the Distressed Communities Index, and the incidence of firearm injuries in Maryland. The findings underscore the importance of addressing socioeconomic disparities and implementing targeted interventions to reduce firearm-related injuries in economically distressed communities.

The Impact of Obesity on Early Complications Following Tracheostomy: An Evaluation of a Nationwide Registry.

INTRODUCTION: The obesity epidemic is an important public health problem in the United States. Previous studies have revealed the association between obesity and various surgical complications. Tracheostomy which is an important lifesaving procedure may prove technically challenging in an obese patient. This study sought to evaluate the association between obesity and early complications following standard tracheostomy using a national registry. METHODS: Adult patients who underwent tracheostomy from 2007 to 2017 were analyzed using the Nationwide Inpatient Sample (NIS). The population was stratified into obese and non-obese groups. Early complications following standard tracheostomy were identified and compared between the two groups. Multivariable logistic regression analyses were performed to assess the association between obesity and early complications following tracheostomy. RESULTS: Data pertaining to 205 032 adult patients were evaluated. Obese patients accounted for 12.1% (n = 21 816) of the entire cohort. The most common complication in the cohort was perioperative bleeding (4316 [2.1%]). A total of 1382 (0.67%), 949 (0.46%), and 134 (0.07%) patients developed pneumothorax/pneumomediastinum, stoma/surgical site infection, and tracheal injury following standard tracheostomy, respectively. There was no difference in the odds of tracheal injury, perioperative bleeding, and pneumomediastinum/pneumothorax following standard tracheostomy in the obese and non-obese group in multivariable analysis. However, obesity was associated with 60% increased odds of developing stoma/surgical site infection following standard tracheostomy (OR 1.60 [1.33-1.92], P < 0.01). CONCLUSION: Obesity is associated with an increased risk of developing stoma/surgical site infection following standard tracheostomy. This adds to the growing need for measures to help curb the obesity epidemic in a bid to improve surgical outcomes.

A multicenter, citywide report on recurrent violent injury.

INTRODUCTION: The incidence of and risk factors for recurrent violent trauma are not well known. This information is needed to focus violence prevention efforts on at-risk cohorts. The purpose of this study was to determine the incidence of and risk factors for recurrence following violent injury in a large urban setting. We hypothesize that the overall incidence of recurrent violent injury is low but there are specific at-risk cohorts. METHODS: A retrospective, citywide study of patients who sustained blunt assault or penetrating trauma from 2013 to 2019 was performed. Patients were tracked across all trauma centers using their name and date of birth. The primary outcome was incidence of recurrent violent injury, which was calculated by dividing the number of readmitted patients by the number who survived previous admissions due to penetrating trauma or blunt assault. Associations between readmission and injury severity score, abbreviated injury score, age, sex, hospital, mechanism of injury (MOI), and disposition were determined. Kaplan-Meier curves were plotted to determine the incidence of recurrent injury over time. A multivariable Cox proportional hazard model was used to examine the relationships between characteristics at first admission and time-to-readmission. RESULTS: The recurrent injury rate was 836 patients (6.33%) out of 13,211 injured patients. Male, age 14-45 years old, discharge to jail or left against medical advice, and moderate/severe head injury were associated with re-injury. There was no association between recurrence and mechanism of injury or overall injury severity. Discharge to home was associated with a lower re-injury rate. CONCLUSION: The low recurrent injury rate despite high injury prevalence suggests injury prevention efforts should target this demographic and their non-injured peers.

Predictors of Completed Suicides Among Emergency Department Visits for Attempted Suicides.

BACKGROUND: The objective of this study was to identify predictors of mortality among patients presenting to the emergency department (ED) with attempted suicides. METHODS: We analyzed data on emergency department (ED) visits for attempted suicides from the Nationwide Emergency Department Sample (NEDS) database from January 2010 to December 2017. The predictors of mortality were determined in multivariate analysis including age, sex, insurance, annual income, region of the country, mechanism of injury, mental health conditions (schizophrenia; depression; and anxiety, bipolar, and personality disorders), chronic illnesses (hypertension, diabetes, obesity, and dementia), and social risk factors such as alcohol addiction, smoking, and substance abuse. RESULTS: From 2010 to 2017, there were 979,383 ED visits for attempted suicides in the NEDS database. Among these patients, 10,301 (1.1%) died. Of these completed suicides, 73.9% were male with the median age of 43 years (IQR, 30) while the unsuccessful suicide attempt group had a median age of 30 years (IQR, 24) and were 42.7% male. The most common mechanisms of suicide attempt were poisoning (58.8%) and cut injury (25.6%). Gunshot was the most lethal mechanism accounting 40.3% of the completed suicides despite representing 1.3% of the attempts who came to ED. After controlling for common risk factors for attempted suicide, significant predictors of completed suicide include higher income status, uninsured status, male sex, and higher age. DISCUSSION: Among US patients presenting to the ED following attempted suicide, factors associated with suicide completion include increasing age, male sex, higher income, gunshot injuries, and uninsured status.

Disfiguring Firearm Injuries in Children in the United States.

Firearms are a leading cause of injury and death among children in the United States. Most gun violence studies highlight mortality, but few have examined the morbidity in disfiguring injuries suffered by children. Using National Trauma Data Bank 2007-2015, children who suffered gunshot injuries and underwent procedures with lasting physical disfigurement formed the cohort of this study. We identified 28 593 children as victims of firearm injuries. Most were aged 13-18 (84%). There was a preponderance of male gender (86%) and black race/ethnicity (57%). Total mortality was 3774 (13%), and 1500 (5.4%) were identified with one or more disfigurements: 220 amputations, 191 craniectomy, 100 enucleation, 533 ileostomy/colostomy, and 557 tracheostomies. This report highlights the large toll firearm injuries take on American children, specifically in non-concealable disfigurements. These injuries are very impactful to their education and overall socialization and therefore must be a part of the discussion of gun violence in the United States.

Racial/ethnic differences in acute and longer-term posttraumatic symptoms following traumatic injury or illness.

BACKGROUND: Racial/ethnic differences in mental health outcomes after a traumatic event have been reported. Less is known about factors that explain these differences. We examined whether pre-, peri-, and post-trauma risk factors explained racial/ethnic differences in acute and longer-term posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in patients hospitalized following traumatic injury or illness. METHODS: PTSD, depression, and anxiety symptoms were assessed during hospitalization and 2 and 6 months later among 1310 adult patients (6.95% Asian, 14.96% Latinx, 23.66% Black, 4.58% multiracial, and 49.85% White). Individual growth curve models examined racial/ethnic differences in PTSD, depression, and anxiety symptoms at each time point and in their rate of change over time, and whether pre-, peri-, and post-trauma risk factors explained these differences. RESULTS: Latinx, Black, and multiracial patients had higher acute PTSD symptoms than White patients, which remained higher 2 and 6 months post-hospitalization for Black and multiracial patients. PTSD symptoms were also found to improve faster among Latinx than White patients. Risk factors accounted for most racial/ethnic differences, although Latinx patients showed lower 6-month PTSD symptoms and Black patients lower acute and 2-month depression and anxiety symptoms after accounting for risk factors. Everyday discrimination, financial stress, past mental health problems, and social constraints were related to these differences. CONCLUSION: Racial/ethnic differences in risk factors explained most differences in acute and longer-term PTSD, depression, and anxiety symptoms. Understanding how these risk factors relate to posttraumatic symptoms could help reduce disparities by facilitating early identification of patients at risk for mental health problems.

The impact of the affordable care act on access to bariatric surgery in Maryland.

INTRODUCTION: This study aims to investigate the influence of the Affordable Care Act (ACA) on the utilization of Roux-en-Y gastric bypass (RYGB) procedures in Maryland. METHODS: Using the Maryland State Inpatient Database, this retrospective study compared all patients undergoing RYGB during the pre-ACA (2007-2009) and post-ACA (2018-2020) periods, including patient demographic factors, pre-existing conditions, and socioeconomic factors. RESULTS: A total of 16,494 RYGB procedures were performed during the study period, of which 12,089 (73.3 â€‹%) were post-ACA. This was a 179.2 â€‹% increase in patients undergoing RYGB post-ACA; nearly triple that of the pre-ACA period. There was a significant decrease in uninsured patients (5.6 â€‹%-1.5 â€‹%, p â€‹< â€‹0.01) an increase in Black patients (32.1 â€‹%-46.8 â€‹%, p â€‹< â€‹0.01) and Medicaid beneficiaries (6.0 â€‹% pre-ACA to 17.8 â€‹% post-ACA, p â€‹< â€‹0.01). There were significant reductions in adverse outcomes (long hospital stays, hemorrhage, GIT leaks, and mortality) across all insurance types (all p â€‹< â€‹0.01). CONCLUSION: The ACA increased access to RYGB procedures, especially in Black and Medicaid recipients in Maryland, enhancing healthcare across all insurance types.

An Analysis of Preliminary General Surgery Residents' Matriculation into Categorical Positions.

OBJECTIVE: To analyze the effects of a pipeline program for preliminary general surgery (GS) residents to optimize their future enrollment into categorical positions. DESIGN: Retrospective review of non-designated preliminary (NDP) GS residents between 2014 and 2020 was conducted. Preliminary conversion rates (CRs) were analyzed for residents who matriculated to categorical GS residency or non-GS residency positions. SETTING: Howard University Hospital, Department of Surgery; tertiary academic hospital. PARTICIPANTS: PGY-1 (n = 14) and PGY-2 (n = 26) NDP GS residents RESULTS: Forty NDP GS residents studied (14 PGY-1 and 26 PGY-2). CR for the total cohort was 67.5% (n = 27), with 59.3% (n = 16) acquiring categorical GS positions and 40.7% (n = 13) obtaining categorical positions in other specialties. CR for PGY-1 residents into categorical GS position was 50% (n = 7), while PGY-2 residents had a CR of 34.6% (n = 9). No significant difference was observed between residents successfully matriculating into GS residency as a preliminary PGY-1 or PGY-2 (p = 0.34). Twelve preliminary residents secured categorical GS positions at this institution with 58.3% (n = 7) obtaining a PGY-1 position, 16.7% (n = 2) obtaining a PGY-2, and 25.0% (n = 3) obtaining a PGY-3 position. 7.1% (n = 1) of preliminary PGY-1 and 46.2% (n = 12) of preliminary PGY-2 residents went unmatched as of 2021. CONCLUSIONS: 67.5% of preliminary residents enrolled in categorical positions. Success rates were highest during the PGY-1 year. A residency program committed to uniform clinical curriculum, and standardized, metric-based decisions may have increased CR for preliminary GS residents. Public sharing of preliminary CRs to applicants may influence residency selection decisions, both for applicants and programs.

Postmenopausal virilization secondary to a large ovarian cystadenoma with stromal hyperthecosis.

Ovarian cystadenomas may present in a functional manner. Biochemical workup of seemingly benign ovarian lesions should be considered in the appropriate clinical context.

Gallstone Ileus with COVID-19 Infection: An Unintended Sequela of Non-Operative Management of Acute Cholecystitis During the COVID-19 Pandemic.

Appropriate risk stratification and careful follow-up are mandated in elderly patients with comorbidities. Herein, we report a case presenting 5 months after the nonoperative management of acute cholecystitis during the height of the COVID-19 pandemic.

Impact of COVID-19 pandemic on injury prevalence and pattern in the Washington, DC Metropolitan Region: a multicenter study by the American College of Surgeons Committee on Trauma, Washington, DC.

BACKGROUND: The COVID-19 pandemic has had far-reaching effects on healthcare systems and society with resultant impact on trauma systems worldwide. This study evaluates the impact the pandemic has had in the Washington, DC Metropolitan Region as compared with similar months in 2019. DESIGN: A retrospective multicenter study of all adult trauma centers in the Washington, DC region was conducted using trauma registry data between January 1, 2019 and May 31, 2020. March 1, 2020 through May 31, 2020 was defined as COVID-19, and January 1, 2019 through February 28, 2020 was defined as pre-COVID-19. Variables examined include number of trauma contacts, trauma admissions, mechanism of injury, Injury Severity Score, trauma center location (urban vs. suburban), and patient demographics. RESULTS: There was a 22.4% decrease in the overall incidence of trauma during COVID-19 compared with a 3.4% increase in trauma during pre-COVID-19. Blunt mechanism of injury decreased significantly during COVID-19 (77.4% vs. 84.9%, p<0.001). There was no change in the specific mechanisms of fall from standing, blunt assault, and motor vehicle crash. The proportion of trauma evaluations for penetrating trauma increased significantly during COVID-19 (22.6% vs. 15.1%, p<0.001). Firearm-related and stabbing injury mechanisms both increased significantly during COVID-19 (11.8% vs. 6.8%, p<0.001; 9.2%, 6.9%, p=0.002, respectively). CONCLUSIONS AND RELEVANCE: The overall incidence of trauma has decreased since the arrival of COVID-19. However, there has been a significant rise in penetrating trauma. Preparation for future pandemic response should include planning for an increase in trauma center resource utilization from penetrating trauma. LEVEL OF EVIDENCE: Epidemiological, level III.

Patterns and Trends of Gun Violence Against Women in the United States.

OBJECTIVE: To examine patterns and trends of firearm injuries in a nationally representative sample of US women. SUMMARY OF BACKGROUND DATA: Gun violence in the United States exceeds rates seen in most other industrialized countries. Due to the paucity of data little is known regarding demographics and temporal variations in firearm injuries among women. METHODS: Data were extracted from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System (2001-2017) for women 18 years and older. Number of nonfatal firearm assaults and homicide per year were extracted and crude population-based injury rates were calculated. Sub-stratification by age-group and time period were performed. RESULTS: Between 2001 and 2017, there were 88,823 nonfatal firearm assaults involving women and 29,106 firearm homicides. There were 4116 victims of nonfatal firearm assault in 2001 (3.8 per 105) and 12,959 by 2017 (10.0 per 105). Homicide rates were 1.5 per 105 in 2001 and 1.7 per 105 in 2017. Sub-stratification by age-group and time period showed that there were no significant changes in nonfatal firearm assault rates between 2001 and 2010 (P-trend = 0.132 in 18-44 yo; 0.298 in 45-64 yo). However between 2011 and 2017, nonfatal assault rates increased from 7.10 per 105 to 19.24 per 105 in 18-44 yo (P-trend = 0.013) and from 1.48 per 105 to 3.93 per 105 in 45-64 yo (P-trend = 0.003). Similar trends were seen with firearm homicide among 18-44 yo (1.91 per 105 to 2.47 per 105 in 2011-2017, P-trend = 0.022). However, the trends among 45-64 yo were not significant in both time periods. CONCLUSIONS: Female victims of gun violence are increasing and more recent years have been marked with higher rates of firearm injuries, particularly among younger women. These data suggest that improved public health strategies and policies may be beneficial in reducing gun violence against US women.

Risk Factors Associated With Adverse Outcomes After Ventral Hernia Repair With Component Separation.

BACKGROUND: Over 350,000 surgeries are performed for ventral hernias (VHs) annually. Abdominal wall component separation has been more frequently used for the management of VHs. The goal of this study is to better understand factors associated with component separation complication rates. METHODS: The National Inpatient Sample (2005-2014) was used to identify all patients with an International Classification of Diseases ninth Revision diagnosis of VHs who underwent open VH repair with a pedicleor graft advancement flap. All cases included in this study were elective and not associated with additional procedures. Demographic, clinical, and hospital characteristics were extracted. Independent predictors of complications and outcomes were determined by multivariable regression analysis. RESULTS: Component separation was performed in 4346 patients. Mean age was 56; majority were female (55%) and white (80%). Most patients (73%) underwent surgery in an urban teaching hospital; mesh was used in 80% of cases and 11% were smokers. Hypertension was the most common comorbidity (50%), followed by obesity (26%), diabetes mellitus (DM) (23%), coronary artery disease (11%), and chronic obstructive pulmonary disease (COPD) (8%). Half of the patients (50%) had private insurance, and 35% had Medicare. Patients were distributed equally over household income quartiles. The mortality rate was 0.5%; median length of stay was 5 d. Overall complication rate was 25% (wound 11%, intraoperative 5%, infectious 11%, and pulmonary 8%). Mesh was associated with a lower rate of wound complications (10% versus 15%, P = 0.001). On multivariable analysis, patients with COPD (odds ratio: 2.02; 95% confidence interval: 1.58-2.59), obesity (1.37; 1.16-1.63), DM (1.3; 1.09-1.55), and those in the lowest income quartile (1.44; 1.06-1.96) had higher overall complication rates. CONCLUSIONS: Consistent with other studies, patients with COPD, Obesity, DM, and lower income status were associated with increased complications after component separation.

Coronary Artery Bypass Grafting Among Older Adults: Patterns, Outcomes, and Trends.

INTRODUCTION: Although the numbers of older adults in the US are rapidly increasing, there is sparse recent data on the use and outcomes of coronary artery bypass grafting (CABG) among this population. We aimed to evaluate the characteristics and outcomes of older adults undergoing CABG and to measure temporal trends. MATERIALS AND METHODS: Using data from the National Inpatient Sample (2005-2014), patients aged 85 y and older who underwent CABG were selected. Demographic, clinical, and hospital characteristics were extracted. Outcomes measured were hospital mortality, hospital length of stay, discharge home, and operative complications. Patients were grouped by 2-year increments. Differences in clinical characteristics and outcomes over time were evaluated using trend analyses. RESULTS: There were 60,124 patients included in the cohort. The mean age was 86.8 y with majority being men (61%), white (88%), and treated in teaching hospitals (61%). Over the study period, the annual surgical volume decreased from 6689 in 2005/06 to 5150 in 2013/14. Mortality decreased from 8.5% to 5.5% (P-trend <0.001) and mean hospital length of stay decreased from 13.9 d to 12.0 d (P-trend <0.001), whereas the rate of discharge home remained stable (14.1% versus 11.6%, P-trend = 0.056). Compared with patients in 2005/06, those in 2013/14 had higher comorbidities [diabetes: 27.6% versus 17.3%; chronic kidney disease: 29.8% versus 9.2%; peripheral artery disease: 7.5% versus 6.0%; and hypertension: 83.7% versus 64.5% (all P-trend <0.001)]. CONCLUSIONS: CABG volumes are decreasing among older adults, and comorbidity burden is increasing, but outcomes are improving. These data may indicate improved preoperative optimization and better perioperative care processes.

Gunshot Injuries in American Trauma Centers: Analysis of the Lethality of Multiple Gunshot Wounds.

INTRODUCTION: Trauma center care and survival have been improving over the past several years. However, yearly firearm-related deaths have remained near constant at 33 000. One challenge to decreasing gunshot mortality is patients presenting with complex injury patterns from multiple gunshot wounds (GSWs) made possible by high-caliber automated weapons. Our study analyzes outcomes of trauma patients of firearms using the National Trauma Databank (NTDB). METHODS: We conducted a retrospective review of the NTDB from the years 2003-2015 for patients with penetrating injuries. We separated patients into groups based on stab wounds, single GSW, and multiple GSW. We performed multivariate logistic regression analyses in which we adjusted for demographics and injury severity. RESULTS: Overall, 382 376 patients presenting with penetrating injuries were analyzed. Of those 167 671 had stab, 106 538 single GSW, and 57 819 multiple GSW injuries. Crude mortality was 1.97% for stab wounds, 13.26% for single GSW, and 18.84% for multiple GSW. Adjusted odds ratio (OR) compared with 2003 demonstrates a trend toward decreased mortality for stab wounds (OR range of 0.48-0.69, P < .05 for years 2010-2015). A similar trend was demonstrated in single GSW injuries (OR 0.31-0.83, P < .01 for years 2005-2015). Conversely, multiple GSW injuries did not follow this trend (OR 0.91-1.36 with P > 0.05 for each year). CONCLUSION: In contrast to significant improvement in survival in patients with a single GSW injury since 2003, multiple GSW injuries still pose a challenge to trauma care. This warrants further investigation into the efficacy of legislature, and the lack thereof, as well as future preventative measures to this type of injury.