12 research outputs found
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Does structural racism impact receipt of NCCN guideline-concordant breast cancer treatment?
Disparities in breast cancer survival remain a challenge. We aimed to analyze the effect of structural racism, as measured by the Index of Concentration at the Extremes (ICE), on receipt of National Cancer Center Network (NCCN) guideline-concordant breast cancer treatment.
We identified patients treated at two institutions from 2005 to 2017 with stage I-IV breast cancer. Census tracts served as neighborhood proxies. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed to create 5 models, controlling for economic segregation, non-Hispanic Black (NHB) segregation, NHB/economic segregation, Hispanic segregation, and Hispanic/economic segregation. Multi-level logistic regression models were used to determine the association between individual and neighborhood-level characteristics on receipt of NCCN guideline-concordant breast cancer treatment.
5173 patients were included: 55.2% were Hispanic, 27.5% were NHW, and 17.3% were NHB. Regardless of economic or residential segregation, a NHB patient was less likely to receive appropriate treatment [(OR)
0.58 (0.45-0.74); OR
0.59 (0.46-0.78); OR
0.62 (0.47-0.81); OR
0.53 (0.40-0.69); OR
0.59(0.46-0.76); p < 0.05].
To our knowledge, this is the first analysis assessing receipt of NCCN guideline-concordant treatment by ICE, a validated measure for structural racism. While much literature emphasizes neighborhood-level barriers to treatment, our results demonstrate that compared to NHW patients, NHB patients are less likely to receive NCCN guideline-concordant breast cancer treatment, independent of economic or residential segregation. Our study suggests that there are potential unaccounted individual or neighborhood barriers to receipt of appropriate care that go beyond economic or residential segregation
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Enhancing surgical internship preparedness through a Transition to Internship Bootcamp
Purpose
This study aims to assess the effectiveness of a 4th-year medical student (MS4) Transition to Internship Bootcamp curriculum in improving students’ attitudes towards and perception of preparedness for surgical residency.
Methods
A 4-week Transition to Internship Bootcamp curriculum was implemented for MS4 students who matched into a surgical residency program. The curriculum consisted of lectures on patient care, common surgical diseases, administrative and surgical principles, and hands-on practice of common bedside procedures and basic operating skills. Students completed a pre- and post-Bootcamp survey that measured their perceptions of preparedness of various intern-level skills. The surveys included a 5-point Likert scale and open response questions on general attitudes. The survey data was analyzed with univariate analysis at
p
< 0.05 and thematic analyses of open responses.
Results
Of the 30 students who participated in the bootcamp, 50% were male and 50% White, with an average age of 27 years. Twenty-eight students completed both pre- and post-Bootcamp surveys and there was a significant increase in perceived preparedness across all bootcamp skills (
p
< 0.001). Prior to the bootcamp, students were concerned of their preparedness for the practical skills required for surgical internship. Following the bootcamp, students indicated an enhanced confidence in both knowledge and skillset.
Conclusions
The Transition to Internship Bootcamp enhances students’ preparedness for surgical internship and their confidence in various surgical skills. Positive response to hands-on skills lab experiences particularly highlights the importance of such training. Implementing specialty-focused training during the MS4 year strengthens readiness and self-assurance for surgical residency
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715 Initial Use of PLA Skin Substitute at a Large Public Safety-Net Hospital
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When is it safe to start thromboprophylaxis after splenic angioembolization?
Thromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events.
All blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ
analysis and multivariate logistic regression at P < .05.
In 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58-0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20-1.81]).
This national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration
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Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center
IntroductionPediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes.MethodsThis was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts.Results4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1–17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities.ConclusionPediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center.Level of evidenceLevel IV, retrospective study
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Optimal Timing for Initiation of Thromboprophylaxis After Hepatic Angioembolization
OBJECTIVETo evaluate the optimal timing of thromboprophylaxis (TPX) initiation after hepatic angioembolization in trauma patients.SUMMARY BACKGROUND DATATPX after hepatic trauma is complicated by the risk of bleeding, but the relative risk after hepatic angioembolization is unknown.METHODSPatients who underwent hepatic angioembolization within 24 hours were retrospectively identified from the 2017-19 ACS TQIP datasets. Cases with <24-hour length of stay and other serious injuries were excluded. VTE included DVT and PE. Bleeding complications included hepatic surgery, additional angioembolization, or blood transfusion after TPX initiation. Differences were tested with univariate and multivariate analyses.RESULTSOf 1,550 patients, 1,370 had initial angioembolization. Bleeding complications were higher in those with TPX initiation within 24 hours (20.0% vs 8.9%, P<0.001) and 48 hours (13.2% vs 8.4%, P=0.013). However, VTE was higher in those with TPX initiation after 48 hours (6.3%vs 3.3%, P=0.025). In the 180 patients with hepatic surgery prior to angioembolization, bleeding complications were higher in those with TPX initiation within 24 hours (72% vs 20%, P <0.001), 48 hours (50% vs 17%, P<0.001), and 72 hours (37% vs 14%, P=0.001). Moreover, DVT was higher in those with TPX initiation after 96 hours (14.3% vs 3.1%, P =0.023).CONCLUSIONThis is the first study to address timing of TPX after hepatic angioembolization in a national sample of trauma patients. For these patients, initiation of TPX at 48- 72 hours achieves the safest balance in minimizing bleeding while reducing the risk of VTE.LEVEL OF EVIDENCELevel III - Retrospective Cohort Study
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A surgical anatomy training session improves knowledge and confidence in identifying anatomical structures among medical students on the surgical clerkship
Purpose
Recent trends in medical education have shifted towards earlier clinical experiences with reduced preclinical time, thereby decreasing didactic time for human anatomy prior to surgical rotations. Here we assess a dedicated program designed to teach relevant general surgery principles to students at the beginning of their surgical clerkship.
Methods
All medical students who rotated on the surgery clerkship from 2022 to 2023 at a single institution were included. Students voluntarily and anonymously completed identical assessments prior to, 24 h after, and 10 weeks after participating in a required 4-h in-person prosection-based anatomy session. The assessment was comprised of (1) written multiple-choice questions, (2) image-based multiple-choice questions using intraoperative photographs, and (3) confidence scoring utilizing a 5-point Likert scale.
Results
Pre-session and post-session and post-clerkship test survey completion rates were 52% (
n
= 104), 27.5% (
n
= 55), and 20% (
n
= 30), respectively. Post-session and post-clerkship test written, image-based, and confidence scores were significantly higher than pre-test scores. Post-session and post-clerkship test scores were not different with the exception of written-based questions.
Conclusions
A focused general surgery anatomy session improves both written-based and image-based test performance as well as overall confidence in medical students’ understanding of surgical anatomy while completing the surgery clerkship. As medical school curricula continue to evolve with earlier clinical exposure at the expense of dedicated anatomy didactics, new methods that teach surgically relevant anatomy should continue to be explored to optimize medical education
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Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients
Relative to other hospitalized patients, trauma patients are younger with fewer comorbidities, but the incidence and outcomes of in-hospital cardiopulmonary arrest (IHCA) with cardiopulmonary resuscitation (CPR) in this population is unknown. Therefore, we aimed to investigate factors associated with survival in trauma patients after IHCA to test the hypothesis that compared to other hospitalized patients, trauma patients with IHCA have improved survival.
Retrospective review of the Trauma Quality Improvement Program database 2017 to 2019 for patients who had IHCA with CPR. Primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital complications, hospital length of stay, intensive care unit length of stay, and ventilator days. Data were compared with univariate and multivariate analyses at P < 0.05.
In 22,346,677 admitted trauma patients, 14,056 (0.6%) received CPR. Four thousand three hundred seventy-seven (31.1%) survived to discharge versus 26.4% in a national sample of all hospitalized patients (P < 0.001). In trauma patients, median age was 55 y, the majority were male (72.2%). Mortality was higher for females versus males (70.3% versus 68.3%, P = 0.026). Multivariate regression showed that older age 1.01 (95% confidence interval (CI) 1.01-1.02), Hispanic ethnicity 1.21 (95% CI 1.04-1.40), and penetrating trauma 1.51 (95% CI 1.32-1.72) were risk factors for mortality, while White race was a protective factor 0.36 (95% CI 0.14-0.89).
This is the first study to show that the incidence of IHCA with CPR is approximately six in 1000 trauma admissions and 31% survive to hospital discharge, which is higher than other hospitalized patients. Age, gender, racial, and ethnic disparities also influence survival
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Immediate Versus Delayed Surgical Management of Infant Cryptorchidism With Inguinal Hernia
Cryptorchidism is commonly treated with orchiopexy at 6-12 months of age, often allowing time for undescended testicle(s) (UT) to descend spontaneously. However, when an inguinal hernia (IH) is also present, some surgeons perform orchiopexy and inguinal hernia repair (IHR) immediately rather than delaying surgery. We hypothesize that early surgical intervention provides no benefit for newborns with both IH and UT.
The Nationwide Readmissions Database was used to identify newborns with diagnoses of both IH and UT from 2010 to 2014. Patients were stratified by management: IHR performed on initial admission (Repair) or not (Deferral). Demographics, outcomes, and complications were compared. Results were weighted for national estimates.
We analyzed 1306 newborns (64% premature) diagnosed with both IH and UT. IHR was performed at index admission in 30%. Repair was more common in premature babies (43% vs. 8% full-term, p < 0.001) and patients with congenital anomalies (33% vs. 27% without congenital anomaly, p = 0.012). There was no difference in readmission rates. Repair patients had higher rates of orchiectomy than did Deferral. No Deferral patients were readmitted for bowel resection, and <1% were readmitted for orchiectomy or hernia incarceration.
In newborns with UT and IH, immediate repair is not associated with improved outcomes. Even with incarceration on initial presentation, rates of readmission with incarceration or bowel compromise for patients who undergo Deferral of surgery are minimal. Moreover, Repair newborns have higher rates of orchiectomy. We found no benefit to early operative intervention; thus, we recommend waiting until 6-12 months of age to reassess for surgery.
Level III TYPE OF STUDY: Retrospective Comparative Study
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Timing of Pediatric Incarcerated Inguinal Hernia Repair: A Review of Nationwide Readmissions Data
In pediatric patients, incarcerated inguinal hernias are often repaired on presentation. We hypothesize that in appropriate patients, repair may be safely deferred.
The Nationwide Readmissions Database was used to identify pediatric patients (aged < 18 y) with incarcerated inguinal hernia from 2010 to 2014. Patients were stratified by management approach (Early Repair versus Deferral). Overall frequencies of these operative strategies were calculated. Propensity score matching was then performed to control for patient age, comorbidities, perinatal conditions, and congenital anomalies. Outcomes including complications, surgical procedures, and readmissions were compared. Outpatient surgeries were not assessed.
Among 6148 total patients with incarcerated inguinal hernia, the most common strategy was to perform Early Repair (88% versus 12% Deferral). Following propensity score matching, the cohort included 1288 patients (86% male, average age 1.7 ± 4.1 years). Deferral was associated with equivalent rates of readmission within one year (13% versus 15%, P = 0.143), but higher readmissions within the first 30 days (7% versus 3%, P = 0.002) than Early Repair. Deferral patients had lower rates of orchiectomy (2% versus 5%, P = 0.001), wound infections (< 2% versus 2%, P = 0.020), and other infections (7% versus 15%, P < 0.001). The frequency of other complications including bowel resection, oophorectomy, testicular atrophy, sepsis, and pneumonia were equivalent between groups. Three percent of Deferrals had a diagnosis of incarceration on readmission.
Deferral of incarcerated inguinal hernia repair at index admission is associated with higher rates of hospital readmissions within the first 30 days but equivalent readmission within the entire calendar year. These patients are at risk of repeat incarceration but have significantly lower rates of orchiectomy than their counterparts who undergo inguinal hernia repair at the index admission. We propose that prospective studies be performed to identify good candidates for Elective Deferral following manual reduction and overnight observation. Such studies must capture outpatient surgical outcomes