Search

This quality improvement study uses Accreditation Council for Graduate Medical Education Milestone evaluation scores to compare the scores of men and women surgical residents.

Congenital posterior urethroperineal fistula (CUPF) is a urothelium-lined tract between the posterior urethra and perineum. This condition is rare and has been proposed to be a urethral duplication variant. A case of CUPF that was misdiagnosed and surgically treated as a rectourethral fistula is presented. The clinical presentation, diagnosis, and treatment of CUPF are discussed and compared with those of Y-type urethral duplications and H-type rectourethral fistulas.

About 1.7 billion children and adolescents, mostly in low- and middle-income countries (LMICs) lack access to surgical care. While some of these countries have developed surgical plans and others are in the process of developing theirs, children's surgery has not received the much-needed specific emphasis and focus in these plans. With the significant burden of children's surgical conditions especially in low- and middle-income countries, universal health coverage and the United Nations' (UN) Sustainable Development Goals (SDG) will not be achieved without deliberate efforts to scale up access to children's surgical care. Inclusion of children's surgery in National Surgical Obstetric and Anaesthesia Plans (NSOAPs) can be done using the Global Initiative for Children's Surgery (GICS)-modified Children's Surgical Assessment Tool (CSAT) tool for baseline assessment and the Optimal Resources for Children Surgical Care (OReCS) as a foundational tool for implementation.

Background: Out-of-pocket payments and catastrophic healthcare expenditures (CHE) are important barriers to achieving equity and access to emergency and essential surgical care in low- and middle-income countries (LMICs), with important implications for universal health coverage (UHC). However, data on CHE for surgical care in these settings are limited, especially with regard to infections. Methods: We performed a retrospective review of 32 children receiving laparotomy for typhoid intestinal perforation in a four-year period. Data on medical costs were reviewed. Because of the lack of reliable data on household incomes and average national incomes for Nigeria, gross domestic product per capita was used to calculate CHE. The GDP per capita for the country during the study period was $2,028.182. Expenditure >10% GDP per capita (or > $202.82) was considered CHE. Results: There were 15 boys and 17 girls aged 2-15 years (mean 7.72 years). Seventeen patients (53%) were referred from district/general hospitals or mission hospitals. After surgical treatment, 16 patients (50%) developed complications (intra-abdominal abscesses and incision complications), and nine (28.1%) required re-operation. Seven patients (21.9%) required intensive care (ICU) treatment and three (9.4%) died from overwhelming infection. The hospital stay was 3-93 days (mean 23 days). The average total medical cost was $452 (range $236-$1,700). The total medical costs exceeded 10% of GDP ($202.82) for all patients. Total expenditure for four patients requiring intensive care exceeded $202.82 for the ICU care alone. Conclusion: Surgical treatment of typhoid intestinal perforation in children is associated with a high rate of CHE if care is provided at tertiary hospitals. Investments in prevention and control of this and other surgical infections as well as scale up of capacity at district hospitals to provide such care are important in preventing CHE.

Background We determined whether in vitro potency assays inform which placental mesenchymal stromal cell (PMSC) lines produce high rates of ambulation following in utero treatment of myelomeningocele in an ovine model. Methods PMSC lines were created following explant culture of three early-gestation human placentas. In vitro neuroprotection was assessed with a neuronal apoptosis model. In vivo, myelomeningocele defects were created in 28 fetuses and repaired with PMSCs at 3 × 105 cells/cm2 of scaffold from Line A (n = 6), Line B (n = 7) and Line C (n = 5) and compared to no PMSCs (n = 10). Ambulation was scored as ≥ 13 on the Sheep Locomotor Rating Scale. Results In vitro, Line A and B had higher neuroprotective capability than no PMSCs (1.7 and 1.8 respectively vs 1, p = 0.02, ANOVA). In vivo, Line A and B had higher large neuron densities than no PMSCs (25.2 and 27.9 respectively vs 4.8, p = 0.03, ANOVA). Line C did not have higher neuroprotection or larger neuron density than no PMSCs. In vivo, Line A and B had ambulation rates of 83% and 71%, respectively, compared to 60% with Line C and 20% with no PMSCs. Conclusion The in vitro neuroprotection assay will facilitate selection of optimal PMSC lines for clinical use. Level of evidence n/a. Type of study Basic science.

Patent ductus arteriosus (PDA) may be found in 0.1–0.2% of term infants, but the average incidence is at least five-fold higher in premature infants, correlating inversely with birth weight and gestational age. While not all patients with a PDA require treatment, the deleterious effects of persistent left-to-right shunting across the ductus can have important short- and long-term consequences. Medical and interventional approaches to PDA closure have evolved greatly in the past decade and add to the decision-making pathways. This article summarizes the pathophysiology of PDA and characterizes the medical, surgical and endovascular treatment approaches.

BACKGROUND AND OBJECTIVES Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. Screening and treatment reduces this risk, but requires multiple examinations of infants, most of whom will not develop severe disease. Previous work has suggested that artificial intelligence may be able to detect incident severe disease (treatment-requiring retinopathy of prematurity [TR-ROP]) before clinical diagnosis. We aimed to build a risk model that combined artificial intelligence with clinical demographics to reduce the number of examinations without missing cases of TR-ROP. METHODS Infants undergoing routine ROP screening examinations (1579 total eyes, 190 with TR-ROP) were recruited from 8 North American study centers. A vascular severity score (VSS) was derived from retinal fundus images obtained at 32 to 33 weeks’ postmenstrual age. Seven ElasticNet logistic regression models were trained on all combinations of birth weight, gestational age, and VSS. The area under the precision-recall curve was used to identify the highest-performing model. RESULTS The gestational age + VSS model had the highest performance (mean ± SD area under the precision-recall curve: 0.35 ± 0.11). On 2 different test data sets (n = 444 and n = 132), sensitivity was 100% (positive predictive value: 28.1% and 22.6%) and specificity was 48.9% and 80.8% (negative predictive value: 100.0%). CONCLUSIONS Using a single examination, this model identified all infants who developed TR-ROP, on average, >1 month before diagnosis with moderate to high specificity. This approach could lead to earlier identification of incident severe ROP, reducing late diagnosis and treatment while simultaneously reducing the number of ROP examinations and unnecessary physiologic stress for low-risk infants.

Background Gastroschisis remains a morbid and costly congenital defect, predominantly owing to sequelae of intestinal dysmotility and malabsorption. Although fetal surgical repair has been demonstrated in a lamb model, it is unclear whether this improves intestinal motility and feeding tolerance. Methods Fetuses from five time-mated ewes (Ovis aries) underwent defect creation at gestational age (GA) 76–80 days. The experimental group underwent in utero repair of gastroschisis at GA 99–100. The positive control group underwent postnatal repair of at time of cesarean section at GA 139–141. On day of birth, lambs were fed barium sulfate, followed by ad lib colostrum/milk. Lambs were monitored for up to 72 h to determine feeding tolerance and duration of time for complete passage of barium through the gastrointestinal tract. Results Eight fetuses underwent gastroschisis defect creation and five survived to birth. Of the three lambs repaired at birth, one required resection of necrotic bowel and two had significant intestinal stricture at the abdominal wall defect and did not tolerate feeding. Of the two lambs repaired in utero, one tolerated feeding normally without complications and one had a small intestine atresia preventing normal feeding. Conclusion Fetal repair of gastroschisis may improve postnatal intestinal motility resulting in feeding tolerance at birth. Study type Prospective comparative study. Level of evidence Level II.

Although the incidence of gastroschisis is increasing, risk factors are not clearly identified.Using the Linked Birth Database from the California Office of Statewide Health Planning and Development from 1995 to 2012, patients with gastroschisis were identified by ICD-9 diagnosis/procedure code or birth certificate designation. Logistic regressions examined demographics, birth factors, and maternal exposures on risk of gastroschisis.The prevalence of gastroschisis was 2.7 cases per 10,000 live births. Patients with gastroschisis had no difference in fetal exposure to alcohol (p = 0.609), narcotics (p = 0.072), hallucinogenics (p = 0.239), or cocaine (p = 0.777), but had higher exposure to unspecified/other noxious substances (OR 3.27, p = 0.040; OR 2.02, p = 0.002). Gastroschisis was associated with low/very low birthweight (OR 5.08-16.21, p 0.001) and preterm birth (OR 3.26-10.0, p 0.001). Multivariable analysis showed lower risk in black (OR 0.44, p 0.001), Asian/Pacific Islander (OR 0.76, p = 0.003), and Hispanic patients (OR 0.72, p 0.001) compared to white patients. Risk was higher in rural areas (OR 1.24-1.76, p = 0.001). Compared to women age 20, risk decreased with advancing maternal age (OR 0.49-OR 0.03, p 0.001). Patients with gastroschisis had increased total charges ($336,270 vs. $9012, p 0.001) and length of stay (38.1 vs. 2.9 days, p 0.001). Mortality was 4.6%.This is the largest population-based study summarizing current epidemiology of gastroschisis in California.Retrospective comparative cohort study.III.

About 1.7 billion children and adolescents, mostly in low- and middle-income countries (LMICs) lack access to surgical care. While some of these countries have developed surgical plans and others are in the process of developing theirs, children's surgery has not received the much-needed specific emphasis and focus in these plans. With the significant burden of children's surgical conditions especially in low- and middle-income countries, universal health coverage and the United Nations' (UN) Sustainable Development Goals (SDG) will not be achieved without deliberate efforts to scale up access to children's surgical care. Inclusion of children's surgery in National Surgical Obstetric and Anaesthesia Plans (NSOAPs) can be done using the Global Initiative for Children's Surgery (GICS)-modified Children's Surgical Assessment Tool (CSAT) tool for baseline assessment and the Optimal Resources for Children Surgical Care (OReCS) as a foundational tool for implementation.

Objective We seek to identify the current role and practices of the surgery morbidity and mortality (M&M) conference in academic surgery departments in the United States and Canada. Design, Setting, and Participants All members of the Society of Surgical Chairs, a program of the American College of Surgeons, were e-mailed an IRB-approved 28-question electronic survey in fall 2017. Up to 3 reminders were sent. Results Responses from 129/186 (69%) departments of surgery were received. Nearly all departments (96%) continue to have a departmental M&M conference. The M&M conference is typically weekly (93%), between 7 and 9 AM (80%), on weekdays during which there are no scheduled elective operations (84%). Attendance is mandatory for residents (98%), but required for faculty in only 49% of departments. Fewer than half of all departments (44%) have written guidelines as to which complications should be reported to M&M. Most conferences are prepared case presentations (89%), but may include unprepared discussions (17%), case-based educational presentations (30%), or a combination (28%). The most common classification category was by root case of the error (60%) and preventability (58%). Most departments keep electronic and/or physical M&M reports, while 21% maintain a relational database and 25% do not retain records. While almost all (96%) departments reported participating in at least one national quality improvement program, these are not often linked to the M&M process. Conclusions M&M is predominantly seen as an educational conference based on a few select cases. Departmental quality is monitored with hospital-driven or national quality improvement efforts. Integration of hospital-based quality metric programs with surgery M&M conference is uncommon and represents an opportunity for hospital-department collaboration.

This study seeks to update current epidemiology of Hirschsprung disease (HD) in California. Using data from the California Office of Statewide Health Planning and Development Linked Birth (1995–2012) and Patient Discharge Databases (1995–2013), patients from either dataset with an ICD-9 diagnosis code of HD (751.3) or procedure code of Soave (48.41), Duhamel (48.65), or Swenson/other pull-through (48.49) were included. Patients > age 18 during their first admission were excluded. Of 9.3 million births, 2,464 patients were identified. Incidence was 2.2 cases/10,000 live births, with rates peaking at 2.9/10,000 births in 2002. Incidence was highest among African American (4.1/10,000) and Asian/Pacific Islander (2.5/10,000) births. Most were male (n = 1652, 67.1%). Sixty patients (2.4%) had Down syndrome. The median gestational age at birth was 38 weeks 6 days (interquartile range [IQR] 37 weeks 1 day–40 weeks 1 day). Mortality during the first year of life was 1.7%. Median age at death was 14.5 days (IQR 0–113 days). This is one of the largest population-based studies of HD. In California, the incidence of HD is stable, risk is highest among African American children, and the mortality rate is

Background Traditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these 2 methods might not overlap. Study Design This is a retrospective observational study of all hospitalizations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event (PSIs 03, 05 to 15) identified by surgery faculty and residents for review by departmental M&M conference or administrative data (according to AHRQ, version 6.0). Pediatric cases were excluded. We analyzed the degree to which these 2 processes captured PSI-defined events and reasons for exclusion by each process. Results Among 6,563 surgical hospitalizations, 647 hospitalizations (9.9%) had at least 1 complication identified by the M&M process or the PSIs (or both). Of these hospitalizations, 116 had at least 1 PSI-defined event (for a total of 149 PSI-defined events) captured by either M&M or the PSIs. Most complications (n = 82 [88.2%]) identified by M&M alone were excluded by PSI criteria (as intended), but 11 true PSI events (ie false negatives) were identified by M&M only. In contrast, pressure ulcers and central venous catheter-related bloodstream infections were detected exclusively by the PSIs and not reported via M&M. There was limited overlap, with 18 events (12.1%) captured by both processes. Conclusions Surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.

This abstract was presented as a quickshot presentation at the 2020 Academic Surgical Congress. BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular adjunct to hemorrhage control. Success relies upon institutional support and focused training in arterial access. We hypothesized that hospitals with higher REBOA volumes will be more successful than low-volume hospitals at aortic occlusion with REBOA. METHODS: This is a retrospective study from the American Association for the Surgery of Trauma (AAST) Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry from 11/2013–01/2018. Patients ≥ 18 years who underwent REBOA were included. Successful placement of REBOA catheters (defined as hemodynamic improvement with balloon inflation) was compared between high-volume (≥80 cases; 2 hospitals), mid-volume (10–20 cases; 4 hospitals), and low-volume (

Adrenocortical tumors (ACTs) are rare in children, comprising

Objective/Purpose Retinopathy of prematurity (ROP) is a leading cause of childhood blindness related to oxygen exposure to the developing retina in premature infants. Since oxygen monitoring protocols have reduced the incidence of treatment-requiring ROP (TR-ROP), it remains unclear whether oxygen exposure remains a relevant risk factor for incident TR-ROP and aggressive ROP (A-ROP), a severe, rapidly progressing form of ROP. The purpose of this proof-of-concept study was to use electronic health record (EHR) data to evaluate early neonatal oxygen exposure as a predictive variable for developing TR-ROP and A-ROP. Design Retrospective cohort study. Subjects, Participants, and/or Controls 244 infants screened for ROP at a single academic center. Methods Intervention, or Testing: For each infant, oxygen saturations and fraction of inspired oxygen (FiO₂) were manually extracted from the EHR until 31 weeks PMA. Cumulative minimum, maximum, mean oxygen saturation and FiO₂ were calculated on a weekly basis. Random forest models were trained with 5-fold cross-validation using GA and cumulative minimum FiO₂ at 30 weeks PMA to identify infants who developed TR-ROP. Secondary ROC analysis on infants with/without A-ROP was performed without cross-validation due to small numbers. Main Outcomes/Measures For each model, cross-validation performance for incident TR-ROP was assessed using area under the receiver operating curve (AUROC) and precision-recall curve (AURPC) scores. For A-ROP, we calculated AUROC, and evaluated sensitivity and specificity at a high-sensitivity operating point. Results Of the 244 infants included, 33 developed TR-ROP and 5 were diagnosed with A-ROP. For incident TR-ROP, random forest models trained on GA plus cumulative minimum FiO₂ (AUROC=0.93±0.06, AUPRC=0.70±0.08) were not significantly better those trained on GA alone (AUROC=0.92±0.06, p=0.59; AUPRC=0.74±0.12, p=0.32). However, models using oxygen alone had an AUROC of 0.80±0.09. Secondary ROC analysis for A-ROP found an AUROC=0.92 [95% CI 0.87-0.96]. Conclusions Oxygen exposure can be extracted from the EHR and quantified as a risk factor for incident TR-ROP and A-ROP. Extracting quantifiable clinical features from the EHR may be useful in the future for building integrative risk models for multiple diseases, and evaluating the complex relationships between oxygen exposure, ROP, and other sequelae of prematurity.

Multisystem inflammatory syndrome in children (MIS-C) is an identified complication of the COVID-19 infection. A common presentation of both COVID-19 and MIS-C is acute abdominal pain, sometimes mimicking appendicitis. We report two cases of patients initially diagnosed with appendicitis who either presented with or developed signs of shock and were found to have MIS-C. An 8-year-old girl who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) presented with fever, abdominal pain, and shock with ultrasound findings consistent with acute appendicitis. After being treated for MIS-C, she underwent appendectomy and improved. Final pathology was consistent with acute appendicitis. A 9-year-old girl who tested negative for COVID RT-PCR presented with uncomplicated appendicitis and underwent laparoscopic appendectomy, but developed post-operative fever and shock. Antibody testing was positive and she responded to treatment for MIS-C. Histology showed lymphohistiocytic inflammation within the muscularis propria, mesoappendix and serosa without the typical neutrophil-rich inflammation and mucosal involvement of acute appendicitis. The diagnosis was MIS-C, not appendicitis. Given the new reality of the COVID-19 pandemic, pediatric surgeons must be aware of MIS-C as a possible diagnosis and should understand the diagnostic criteria and current treatment guidelines.

Background/purpose Reimbursement penalties for excess hospital readmissions have begun for the pediatric population. Therefore, research determining incidence and predictors is critical. Methods A retrospective review of University HealthSystem Consortium database (N=258 hospitals; 2,723,621 patients) for pediatric patients (age 0–17years) hospitalized from 9/2011 to 3/2015 was performed. Outcome measures were 7-, 14-, and 30-day readmission rates. Hospital and patient characteristics were evaluated to identify predictors of readmission. Results Readmission rates at 7, 14, and 30days were 2.1%, 3.1%, and 4.4%. For pediatric surgery patients (N=260,042), neither index hospitalization length of stay (LOS) nor presence of a complication predicted higher readmissions. Appendectomy was the most common procedure leading to readmission. Evaluating institutional data (N=5785), patients admitted for spine surgery, neurosurgery, transplant, or surgical oncology had higher readmission rates. Readmission diagnoses were most commonly infectious (37.2%) or for nausea/vomiting/dehydration (51.1%). Patients with chronic medical conditions comprised 55.8% of patients readmitted within 7days. 92.0% of patients requiring multiple rehospitalizations had comorbidities. Conclusions Readmission rates for pediatric patients are significantly lower than adults. Risk factors for adult readmissions do not predict pediatric readmissions. Readmission may be a misnomer for the pediatric surgical population, as most are related to chronic medical conditions and other nonmodifiable risk factors. Level of Evidence Level IV.

The adult rodent spinal cord presents an inhibitory environment for donor cell survival, impeding efficiency for xenograft-based modeling of gliomas. We postulated that mild thermal preconditioning may influence the fate of the implanted tumor cells. To test this hypothesis, high-grade human astrocytoma G55 and U87 cells were cultured under 37°C and 38.5°C to mimic regular experimental or core body temperatures of rodents, respectively. In vitro, the 38.5°C-conditioned cells, relative to 37°C, grew slightly faster. Compared to U87 cells, G55 cells demonstrated a greater response to the temperature difference. Hyperthermal culture markedly increased production of Hsp27 in most G55 cells, but only promoted transient expression of cancer stem cell marker CD133 in a small cell subpopulation. We subsequently transplanted G55 cells following 37°C or 38.5°C culture into the C2 or T10 spinal cord of adult female immunodeficient rats (3 rats/each locus/per temperature; total: 12 rats). Systematic analyses revealed that 38.5°C-preconditioned G55 cells grew more malignantly at either C2 or T10 as determined by tumor size, outgrowth profile, resistance to bolus intratumor administration of 5-fluorouracil (0.1 μmol), and posttumor survival ( p < 0.05; n = 6/group). Therefore, thermal preconditioning of glioma cells may be an effective way to influence the in vitro and in vivo oncological contour of glioma cells. Future studies are needed for assessing the potential oncogenic modifying effect of hyperthermia regimens on glioma cells.

This chapter describes the surgical procedure for silo placement for gastroschisis. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: ensure adequate sedation and analgesia, decompress the colon to express meconium, choose a silicone spring-loaded silo with the diameter chosen based on the size of the defect, place the eviscerated intestines in the bag and place the ring inside the abdomen underneath the fascia, reduce over several days.

IntroductionConfronted with the opioid epidemic, surgeons must play a larger role to reduce risk of opioid abuse while managing acute pain. Having a better understanding of the beliefs and practices of trauma and acute care surgeons regarding discharge pain management may offer potential targets for interventions beyond fixed legal mandates.MethodsAn Institutional Review Board-approved electronic survey was sent to trauma and acute care surgeons who are members of the American Association for the Surgery of Trauma, and trauma and acute care surgeons and nurse practitioners at a Level 1 trauma center in February 2018. The survey included four case-based scenarios and questions about discharge prescription practices and beliefs.ResultsOf 66 respondents, most (88.1%) were at academic institutions. Mean number of opioid tablets prescribed was 20–30 (range 5–90), with the fewest tablets prescribed for elective laparoscopic cholecystectomy and the most for rib fractures. Few prescribed both opioid and non-opioid medications (22.4% to 31.4 %). Most would not change the number/strength of medications (69.2%), dose (53.9%), or number of tablets of opioids (83.1%) prescribed if patients used opioids regularly prior to their operation. The most common factors that made providers more likely to prescribe opioids were high inpatient opioid use (32.4%), history of opioid use/abuse (24.5%), and if the patient lives far from the hospital (12.9%). Most providers in practice >5 years reported a decrease in opioids (71.9%) prescribed at discharge.ConclusionTrauma and acute care surgeons and nurse practitioners reported decreasing the number/amount of opioids prescribed over time. Patients with high opioid use in the hospital, history of opioid use/abuse, or who live far from the provider may be prescribed more opioids at discharge.Level of evidenceLevel IV.

This chapter describes the surgical procedure for sutureless repair of gastroschisis. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: ensure adequate sedation and analgesia, decompress the colon to express meconium (or remove the silo, if this was a staged closure), reduce the abdominal contents (taking care to monitor for and avoid abdominal compartment syndrome), and loop a long segment of the intact umbilical cord over the defect and secure in place with a sterile dressing.

This chapter describes the surgical procedure for operative sutured repair of gastroschisis. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: ensure adequate sedation and analgesia, decompress the colon to express meconium (or remove the silo, if this was a staged closure), enlarge the abdominal wall defect if necessary, reduce the abdominal contents (taking care to monitor for and avoid abdominal compartment syndrome), and close the abdominal wall defect primarily.

In the original article there is an error in Fig. 2. Following is the corrected figure.

This is a baseline assessment of surgical capacity in the Federal Capital Territory (FCT), in preparation for the creation of a National Surgical, Obstetric, Anesthesia, and Nursing Plan. In October 2017, all 10 of the 11 secondary hospitals in FCT that provide surgical and/or obstetric care were surveyed using a modified World Health Organization Hospital Assessment Tool and a qualitative semi-structured hospital interview tool of the medical Director (MdD). This project received approval from the Nigeria Federal Ministry of Health and the FCT Department of Health and Human Services. The number of inpatient beds ranged from 35 to 140, and the number of admissions ranged from 1200 to 6400 patients per year. The mean number of surgeries performed in 2016 by these hospitals was 783 (range 235–1601). Cesarean section was the most common surgical procedure at each hospital. Only five hospitals regularly performed laparotomies. Only three hospitals regularly performed fixation of open fractures. Of 152 surgical, obstetric, and anesthesia providers, all hospitals had at least one consultant obstetrician, but only four hospitals had a general surgeon and three hospitals had a consultant anesthesiologist. Deficient physical space for inpatient admissions was the most common concern of MdDs. The FCT reaches the target for 2-h access, with 80% of patients (on average) reaching the hospital within 2 h. However, SAO provider density, surgical volume, and tracking of the perioperative mortality rate were low. Data were lacking to comment on protection against impoverishing and catastrophic expenditures.

Aims Patients with chronic kidney disease (CKD) on dialysis commonly develop hyperparathyroidism (HPT), but are often not referred for surgical evaluation because of the belief that the cardiopulmonary risks of a parathyroidectomy are prohibitively high. Previous studies have not adequately determined the surgical risks of parathyroidectomy in this population. Materials and methods We used the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2013 to evaluate risk of complications for dialysis vs nondialysis patients undergoing parathyroidectomy using univariate and multivariate logistic regressions. We also compared outcomes between dialysis patients undergoing parathyroidectomy and arteriovenous fistula (AVF) creation to understand the relative risk between these procedures. Results A total of 28,438 patients underwent parathyroidectomy; 1,833 (6.5%) were on dialysis. Among patients undergoing parathyroidectomy, unadjusted mortality and complication rates were higher for patients on dialysis compared to those not on dialysis (1.4% vs 0.1%, p < 0.001; 7.9% vs 1.4%, p < 0.001). Multivariate analysis found increased odds of mortality, all complications, and cardiopulmonary complications among patients on dialysis compared to those not on dialysis [odds ratio (OR) 5.28, p = 0.004; 2.10, p < 0.001; 5.14, p < 0.001]. When compared to patients undergoing parathyroidectomy, dialysis patients undergoing AVF had no difference in odds of death (p = 0.392) or cardiopulmonary complications (p = 0.138), but did have an increased risk of any complication (OR 1.66, p = 0.035). Conclusion Dialysis patients undergoing parathyroidectomy have an increased risk of cardiopulmonary complications and mortality compared to patients not on dialysis; however, these risks are similar to patients undergoing AVF creation. The risks of parathyroidectomy in dialysis patients are likely similar to other commonly performed procedures for dialysis patients. Clinical significance: The risk of mortality and complications should be discussed during informed consent with dialysis patients undergoing parathyroidectomy. These findings can also assist in preoperative risk assessments. How to cite this article Anderson JE, Olson JL, Campbell MJ. Parathyroidectomy in Dialysis Patients: What is the Risk? World J Endoc Surg 2016;8(3):193-198.

High disease burden and inadequate resources have formed the basis for advocacy to improve surgical care in low- and middle-income countries (LMICs). Current measures are heavily focused on availability of resources rather than impact and fail to fully describe how surgery can be more integrated into health systems. We propose a new monitoring and evaluation framework of surgical care in LMICs to integrate surgical diseases into broader health system considerations and track efforts toward improved population health. Although more discussion is required, we seek to broaden the dialogue of how to improve surgical care in LMICs through this comprehensive framework.

This study examines unmanaged chronic medical and psychiatric conditions in hospitalized trauma patients.

This database study uses the 2005-2011 American College of Surgeons National Surgical Quality Improvement Project database to evaluate the association of patient frailty with complications after adrenalectomy.

Purpose The purpose of this study was to determine whether seeding density of placental mesenchymal stromal cells (PMSCs) on extracellular matrix (ECM) during in utero repair of myelomeningocele (MMC) affects motor function and neuronal preservation in the ovine model. Methods MMC defects were surgically created in 33 fetuses and repaired following randomization into four treatment groups: ECM only (n = 10), PMSC-ECM (42 K cells/cm2) (n = 8), PMSC-ECM (167 K cells/cm2) (n = 7), or PMSC-ECM (250–300 K cells/cm2) (n = 8). Motor function was evaluated using the Sheep Locomotor Rating Scale (SLR). Serial sections of the lumbar spinal cord were analyzed by measuring their cross-sectional areas which were then normalized to normal lambs. Large neurons (LN, diameter 30–70 μm) were counted manually and density calculated per mm2 gray matter. Results Lambs treated with PMSCs at any density had a higher median SLR score (15 [IQR 13.5–15]) than ECM alone (6.5 [IQR 4–12.75], p = 0.036). Cross-sectional areas of spinal cord and gray matter were highest in the PMSC-ECM (167 K/cm2) group (p = 0.002 and 0.006, respectively). LN density was highest in the greatest density PMSC-ECM (250–300 K/cm2) group (p = 0.045) which positively correlated with SLR score (r = 0.807, p Conclusions Fetal repair of myelomeningocele with high density PMSC-ECM resulted in increased large neuron density, which strongly correlated with improved motor function. Type of study Basic science. Level of evidence N/A

This population-based study examines the incidence of gastroschisis in California over time and by county.

Objective Abusive head trauma is the leading cause of physical abuse deaths in children under the age of 5 and is associated with severe long-lasting health problems and developmental disabilities. This study evaluates the long-term impact of AHT and identifies factors associated with poor long-term outcomes (LTOs). Methods We used the Truven Health MarketScan Research Claims Database (2000–2015) to identify children diagnosed with AHT and follow them up until they turn 5. We identified the incidence of behavioral disorders, communication deficits, developmental delays, epilepsy, learning disorders, motor deficits, and visual impairment as our primary outcomes. Results The incidence of any disability was 72% (676/940) at 5 years post-injury. The rate of developmental delays was 47%, followed by 42% learning disorders, and 36% epilepsy. Additional disabilities included motor deficits (34%), behavioral disorders (30%), visual impairment (30%), and communication deficits (11%). Children covered by Medicaid experienced significantly greater long-term disability than cases with private insurance. In a propensity-matched cohort that differ primarily by insurance, the risk of behavioral disorders (RD 36%), learning disorders (RD 30%), developmental delays (RD 30%), epilepsy (RD 18%), and visual impairment (RD 12%) was significantly higher in children with Medicaid than kids with private insurance. Conclusion AHT is associated with a significant long-term disability (72%). Children insured by Medicaid have a disproportionally higher risk of long-term disability. Efforts to identify and reduce barriers to health care access for children enrolled in Medicaid are critical for the improvement of outcomes and quality of life.

Background Data suggest that methamphetamine may increase the risk of nonocclusive mesenteric ischemia (NOMI). We describe patterns of presentation and outcomes of patients with methamphetamine use who present with NOMI to a single institution. Methods This is an observational study of patients from January 2015 to September 2017 with methamphetamine use who presented with NOMI at an academic medical center in Northern California. We summarize patient comorbidities, clinical presentation, operative findings, pathologic findings, hospital course, and survival. Results Ten patients with methamphetamine use and severe NOMI were identified. One patient was readmitted with a perforated duodenal ulcer, for a total of 11 encounters. Most presented with acute (n = 3) or acute-on-chronic (n = 4) abdominal pain. Distribution of ischemia ranged from perforated duodenal ulcer (n = 3), ischemia of the distal ileum (n = 1), ischemia of entire small bowel (n = 2), and patchy necrosis of entire small bowel and colon (n = 5). Six patients died, three within 1 week of admission and three between 3 months and 8 months. Conclusion Methamphetamine use may be associated with significant microvascular compromise, increasing the risk of mesenteric ischemia. Providers in areas with high prevalence of methamphetamine use should have a high index of suspicion for intestinal ischemia in this patient population. Patients with methamphetamine use admitted for trauma or other pathology may be at particular risk of ischemia and septic shock, especially in the setting of dehydration. Use of vasoconstrictors in this patient population may also exacerbate intestinal ischemia. Level of evidence Therapeutic Case series study, level V.

We report an efficient and effective device to reproducibly model clinically relevant spinal cord injury (SCI) via controlled mechanical compression. In the present study, following skin incision, dorsal laminectomy was performed to expose T10 spinal cord of adult female Sprague–Dawley rats (230–250 g). The vertebral column was suspended and stabilized by Allis clamps at T8 and 12 spinous processes. A metal impounder was then gently loaded onto T10 dura (20, 35 or 50 g × 5 min; n = 7/group), resulting in acute mild, moderate, or severe standing weight compression, respectively. Neurobehavioral outcomes were evaluated using the BBB locomotor scale and inclined plane test for coordinated hindlimb function, and a battery of spinal reflex tests for sensorimotor functions, at 1 day following SCI and weekly thereafter for 7 weeks. Quantitative histopathology was used to assess injury-triggered loss of white matter, gray matter and ventral horn motor neurons. Immunocytochemical levels of glial fibrillary acidic protein (GFAP) and β-amyloid precursor protein (APP) at the cervical and lumbar regions were measured to determine the distal segment impact of T10 compression. The data demonstrates that the standardized protocol generates weight-dependent hindlimb motosensory deficits and neurodegeneration primarily at and near the lesion epicenter. Importantly, there are significantly increased GFAP and APP expressions in spinal cord segments involved in eliciting post-SCI allodynia. Therefore, the described system reliably produces compression trauma in manners partially emulating clinical quasi-static insults to the spinal cord, providing a pragmatic model to investigate pathophysiological events and potential therapeutics for compression SCI.

Improved outcomes have been associated with various methods of size matching between expanded criteria (ECD) donors and recipients. A novel method for improved functional based matching was developed utilizing manipulation of Cockcroft-Gault estimated creatinine clearances for donor and recipient. We hypothesized that optimal clearance-based matches would have superior outcomes for both immediate graft function and long-term graft survival. For the analysis, recipients of ECD kidneys in the Scientific Registry of Transplant Recipients (SRTR) transplanted between October 1, 1987 and August 31, 2011 were included. Univariate and multivariate analyses predicted the hazard ratio of graft failure and the odds ratio of requiring dialysis within the first week. A total of 25,640 ECD kidney transplants were analyzed. On multivariate analysis, higher creatinine clearance match ratio (CCMR) was associated with increased graft failure and odds of requiring dialysis within the first week (comparing highest ratio quintile versus lowest ratio quintile: HR 1.43, p < 0.001; OR 2.08, p < 0.001). This study suggests that ECD kidneys have improved outcomes when the recipient/donor CCMR is optimized.