Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

COMPARISON OF MALE AND FEMALE VICTIMS OF INTIMATE PARTNER HOMICIDE AND BIDIRECTIONALITY- AN ANALYSIS OF THE NATIONAL VIOLENT DEATH REPORTING SYSTEM

Intimate partner violence (IPV) is a public health crisis, affecting at least 1:4 women and 1:9 men. A recent multi-center trial on universal screening in trauma patients showed similar rates of positive screens between men and women. Few studies have explored the bidirectional violence in opposite sex or same sex relationships. Our goal was to estimate prevalence and risk factors for the most severe manifestation of IPV: intimate partner homicide (IPH). This is a 2003-2015 retrospective review of the National Violent Death Reporting System (NVDRS), a CDC database of surveillance data. Deaths were coded IPV if the primary relationship between the suspect and victim fell into the categories of "current partner" or "ex-partner." Bivariable and multivariable analysis examined differences between groups for factors and circumstances. 6,131 persons in opposite-sex relationships and 181 in same-sex relationships were murdered due to IPV. Women and Black men were disproportionately affected, and alcohol and preceding arguments were a factor in a higher proportion of male victims. Abuse preceded homicide in many women with almost half of male suspects attempting or committing suicide at the time of IPH. Women were more likely than men to use a stabbing instrument, although firearms were still the most common means for each group. In 46.5% of homicides of women, the male suspect attempted suicide (p <0.001). Bidirectionality was highest in male victims of female perpetrators, and in same-sex pairings regardless of sex of the victim. Homicide due to IPV is a significant public health crisis for both men and women, with women and Black men at particular risk. Firearms are the most commonly used weapon for homicide in both genders, and mental illness is not a common risk factor. A staggering proportion of these homicides involve suicide of the suspect, suggesting that each potential incident has two victims to target for prevention and intervention. Interventional programs to prevent such bidirectional mortality are urgently needed. III STUDY TYPE: Retrospective Secondary Data Analysis

Undertriage of older trauma patients: is this a national phenomenon?

Background: Older age is associated with high rates of morbidity and mortality after injury. Statewide studies suggest significantly injured patients aged ≥55 y are commonly undertriaged to lower level trauma centers (TCs) or nontrauma centers (NTCs). This study determines whether undertriage is a national phenomenon. Materials and methods: Using the 2011 Nationwide Emergency Department Sample, significantly injured patients aged ≥55 y were identified by diagnosis and new injury severity score (NISS) ≥9. Undertriage was defined as definitive care anywhere other than level I or II TCs. Weighted descriptive analysis compared characteristics of patients by triage status. Multivariable logistic regression determined predictors of undertriage, controlling for hospital characteristics, injury severity, and comorbidities. Results: Of 4,152,541 emergency department (ED) visits meeting inclusion criteria, 74.0% were treated at lower level TCs or NTCs. Patients at level I and II TCs more commonly had NISS ≥9 (22.2% versus 12.3%, P \u3c 0.001), but among all patients with NISS ≥9, 61.3% were undertriaged to a lower level TC or a NTC. On multivariable logistic regression, factors independently associated with higher odds of being undertriaged were increasing age, female gender, and fall-related injuries. A subgroup analysis examined urban and suburban areas only where access to a TC is more likely and found that 55.8% of patients\u27 age were undertriaged. Conclusions: There is substantial undertriage of patients aged ≥55 y nationwide. Over half of significantly injured older patients are not treated at level I or II TCs. The impact of undertriage should be determined to ensure older patients receive trauma care at the optimal sit

National cost of trauma care by payer status

Background: Several studies have described the burden of trauma care, but few have explored the economic burden of trauma inpatient costs from a payer\u27s perspective or highlighted the differences in the average costs per person by payer status. The present study provides a conservative inpatient national trauma cost estimate and describes the variation in average inpatient trauma cost by payer status.Methods: A retrospective analysis of patients who had received trauma care at hospitals in the Nationwide Inpatient Sample from 2005-2010 was conducted. Our sample patients were selected using the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify admissions due to traumatic injury. The data were weighted to provide national population estimates, and all cost and charges were converted to 2010 US dollar equivalents. Generalized linear models were used to describe the costs by payer status, adjusting for patient characteristics, such as age, gender, and race, and hospital characteristics, such as location, teaching status, and patient case mix.Results: A total of 2,542,551 patients were eligible for the present study, with the payer status as follows: 672,960 patients (26.47%) with private insurance, 1,244,817 (48.96%) with Medicare, 262,256 (10.31%) with Medicaid, 195,056 (7.67%) with self-pay, 18,506 (0.73%) with no charge, and 150,956 (5.94%) with other types of insurance. The estimated yearly trauma inpatient cost burden was highest for Medicare at $17,551,393,082 (46.79$10,772,025,421 [28.72%]), Medicaid ($3,711,686,012 [9.89$2,831,438,460 [7.55%]), and other payer types ($2,370,187,494 [6.32$274,598,190 (0.73%) for patients who were not charged for their inpatient trauma treatment. Our adjusted national inpatient trauma yearly costs were estimated at $37,511,328,659 US dollars. Privately insured patients had a significantly higher mean cost per person than did the Medicare, Medicaid, self-pay, or no charge patients.Conclusions: The results of the present study have demonstrated that the distribution of trauma burden across payers is significantly different from that of the overall healthcare system and suggest that although the burden of trauma is high, the burden of self-pay or nonreimbursed inpatient services is actually lower than that of overall medical care

US emergency department visits for fireworks injuries, 2006-2010

Background: Most literature regarding fireworks injuries are from outside the United States, whereas US-based reports focus primarily on children and are based on datasets which cannot provide accurate estimates for subgroups of the US population. Methods: The 2006-2010 Nationwide Emergency Department Sample was used to identify patients with fireworks injury using International Classification of Diseases, Ninth Revision, Clinical Modification external cause of injury code E923.0. International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were examined to determine the mechanism, type, and location of injury. Sampling weights were applied during analysis to obtain US population estimates. Results: There were 25,691 emergency department visits for fireworks-related injuries between 2006 and 2010. There was no consistent trend in annual injury rates during the 5-y period. The majority of visits (50.1%) were in patients aged \u3c20 y. Most injuries were among males (76.4%) and were treated in hospitals in the Midwest and South (42.0% and 36.4%, respectively) than in the West and Northeast (13.3% and 8.3%, respectively) census regions. Fireworks-related injuries were most common in July (68.1%), followed by June (8.3%), January (6.6%), December (3.4%), and August (3.1%). The most common injuries (26.7%) were burns of the wrist, hand, and finger, followed by contusion or superficial injuries to the eye (10.3%), open wounds of the wrist, hand, and finger (6.5%), and burns of the eye (4.6%). Conclusions: Emergency department visits for fireworks injuries are concentrated around major national holidays and are more prevalent in certain parts of the country and among young males. This suggests that targeted interventions may be effective in combating this public health proble

National cost of trauma care by payer status

Background: Several studies have described the burden of trauma care, but few have explored the economic burden of trauma inpatient costs from a payer\u27s perspective or highlighted the differences in the average costs per person by payer status. The present study provides a conservative inpatient national trauma cost estimate and describes the variation in average inpatient trauma cost by payer status.Methods: A retrospective analysis of patients who had received trauma care at hospitals in the Nationwide Inpatient Sample from 2005-2010 was conducted. Our sample patients were selected using the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify admissions due to traumatic injury. The data were weighted to provide national population estimates, and all cost and charges were converted to 2010 US dollar equivalents. Generalized linear models were used to describe the costs by payer status, adjusting for patient characteristics, such as age, gender, and race, and hospital characteristics, such as location, teaching status, and patient case mix.Results: A total of 2,542,551 patients were eligible for the present study, with the payer status as follows: 672,960 patients (26.47%) with private insurance, 1,244,817 (48.96%) with Medicare, 262,256 (10.31%) with Medicaid, 195,056 (7.67%) with self-pay, 18,506 (0.73%) with no charge, and 150,956 (5.94%) with other types of insurance. The estimated yearly trauma inpatient cost burden was highest for Medicare at $17,551,393,082 (46.79$10,772,025,421 [28.72%]), Medicaid ($3,711,686,012 [9.89$2,831,438,460 [7.55%]), and other payer types ($2,370,187,494 [6.32$274,598,190 (0.73%) for patients who were not charged for their inpatient trauma treatment. Our adjusted national inpatient trauma yearly costs were estimated at $37,511,328,659 US dollars. Privately insured patients had a significantly higher mean cost per person than did the Medicare, Medicaid, self-pay, or no charge patients.Conclusions: The results of the present study have demonstrated that the distribution of trauma burden across payers is significantly different from that of the overall healthcare system and suggest that although the burden of trauma is high, the burden of self-pay or nonreimbursed inpatient services is actually lower than that of overall medical care

Recent release from prison — A novel risk factor for intimate partner homicide

The United States has the highest per-capita incarceration rate and the largest prison population in the world. More than two thirds of recently incarcerated individuals will be arrested again within 3 years of release and may commit crimes as serious as homicide soon after discharge. The pattern of homicidal violence currently remains unknown for recently incarcerated homicide suspects (RIHS) and their victims. A retrospective analysis of the 36 states included in the 2003 to 2017 National Violent Death Reporting System was performed with a focus on RIHS and their victims. Pearson χ2 and Wilcoxon rank sum tests were used for comparison. There were 249 RIHS in the database of the 14,561 homicides where suspect recent incarceration status was documented. Compared with not-recently incarcerated suspects, RIHS were more likely to be White (41% vs. 29%, p < 0.001) and male (97% vs. 91%, p < 0.001). Recently incarcerated homicide suspects more often had a known relationship with the victim (75% vs. 51%, p < 0.001), and these homicides more often occurred in the victim's own home (43% vs. 34%, p = 0.006). Intimate partner violence was a factor in 31% of the RIHS cases (vs. 17%, p < 0.001). The homicide weapon was most likely to be a firearm (57.8%, p < 0.001). Only 6.4% of homicides were due to mental health illness. Gang violence, while more common in the RIHS group, was still only a precipitating factor in 12.0% of the homicides (vs. 7.4%, p = 0.006). Recently incarcerated homicide suspects are more likely to kill a known person in their own home with a firearm, and these homicides are frequently categorized as intimate partner homicides. Gang violence and mental health are not frequent precipitating factors in these deaths. Additional future interventions are urgently needed to eliminate these preventable deaths by alerting previous or current intimate partners of those being discharged from the prison system

Association between race and age in survival after trauma

Importance: Racial disparities in survival after trauma are well described for patients younger than 65 years. Similar information among older patients is lacking because existing trauma databases do not include important patient comorbidity information.Objective: To determine whether racial disparities in trauma survival persist in patients 65 years or older.Design, setting, and participants: Trauma patients were identified from the Nationwide Inpatient Sample (January 1, 2003, through December 30, 2010) using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was ascertained by applying the Trauma Mortality Prediction Model, and patient comorbidities were quantified using the Charlson Comorbidity Index.Main outcomes and measures: In-hospital mortality after trauma for blacks vs whites for younger (16-64 years of age) and older (≥65 years of age) patients was compared using 3 different statistical methods: univariable logistic regression, multivariable logistic regression with and without clustering for hospital effects, and coarsened exact matching. Model covariates included age, sex, insurance status, type and intent of injury, injury severity, head injury severity, and Charlson Comorbidity Index.Results: A total of 1,073,195 patients were included (502,167 patients 16-64 years of age and 571,028 patients ≥65 years of age). Most older patients were white (547,325 [95.8%]), female (406 158 [71.1%]), and insured (567,361 [99.4%]) and had Charlson Comorbidity Index scores of 1 or higher (323,741 [56.7%]). The unadjusted odds ratios (ORs) for death in blacks vs whites were 1.35 (95% CI, 1.28-1.42) for patients 16 to 64 years of age and 1.00 (95% CI, 0.93-1.08) for patients 65 years or older. After risk adjustment, racial disparities in survival persisted in the younger black group (OR, 1.21; 95% CI, 1.13-1.30) but were reversed in the older group (OR, 0.83; 95% CI, 0.76-0.90). This finding was consistent across all 3 statistical methods.Conclusions and relevance: Different racial disparities in survival after trauma exist between white and black patients depending on their age group. Although younger white patients have better outcomes after trauma than younger black patients, older black patients have better outcomes than older white patients. Exploration of this paradoxical finding may lead to a better understanding of the mechanisms that cause disparities in trauma outcomes

Operative delay to laparoscopic cholecystectomy: Racking up the cost of health care

Background: Health care providers are increasingly focused on cost containment. One potential target for cost containment is in-hospital management of acute cholecystitis. Ensuring cholecystectomy within 24 hours for cholecystitis could mitigate costs associated with longer hospitalizations. We sought to determine the cost consequences of delaying operative management. Methods: The Nationwide Inpatient Sample (2003-2011) was queried for adult patients (≥16 years) who underwent laparoscopic cholecystectomy for a primary diagnosis of acute cholecystitis. Patients who underwent open procedures or endoscopic retrograde cholangiopancreatography were excluded. Generalized linear models (GLMs) were used to analyze costs for each day\u27s delay in surgery. Multivariable analyses adjusted for patient demographics, hospital descriptors, Charlson comorbidity index, mortality, and length of stay. Results: We analyzed 191,032 records. Approximately 65% of the patients underwent surgery within 24 hours of admission. The average cost of care for surgery on the admission day was $11,087. Costs disproportionately increased by 22$13,526), by 37% on the third day ($15,243), by 52$16,822), by 64% on the fifth day ($18,196), by 81$20,125), and by 100% on the seventh day ($22,250) when compared with the cost of care for procedures performed within 24 hours of admission. Subset analysis of patients discharged 24 hours or earlier from the time of surgery demonstrated similar trends. Conclusion: After controlling for patient- and hospital-related factors, we noted significant costs associated with each day\u27s delay in operative management. Cost containment practices for acute cholecystitis justify consideration of same-day or next-day surgery where the diagnosis is straightforwar