INTRODUCTION:Emergency department (ED) overcrowding prolongs dwell time; age-related mortality effects remain uncertain. This study evaluated ED dwell time and mortality across pediatric, adult, and older adult trauma populations. METHODS:This retrospective cohort study used the National Trauma Data Bank (2018-2022). Dwell time from ED arrival to ED discharge was described continuously and categorically (0 to 1, 1 to 3, 3 to 8, 8 to 24, >24 h). The exposures of interest were ED dwell time and age. The primary outcome was ED or hospital mortality. Associations between ED dwell time, age, and mortality were evaluated using mixed-effects logistic regression and Cox proportional hazards models. RESULTS:Among 3,701,017 trauma encounters, median ED dwell time was longest among older adults (3.1 h) followed by adults (2.6 h) and pediatric patients (2.4 h). Among patients who died after hospital admission, ED dwell time in older adults (2.1 h) was approximately twice that of adults (1.0 h) and pediatrics (0.8 h). In the mixed-effects model, each additional year of age was associated with a 3.6% increase in mortality odds (adjusted odds ratio [aOR]: 1.036, 95% confidence interval [CI]: 1.03-1.04). In the Cox model, each additional year of age was associated with a 1.3% increase in mortality hazard (hazard ratio [HR]: 1.013, 95% CI: 1.012-1.014). CONCLUSION:Older adults experienced longer ED dwell times and higher adjusted mortality risk. ED dwell time likely reflects both system-level factors, such as operational throughput and patient-level factors, including injury presentation and physiologic vulnerability. These findings support age-informed triage and early risk stratification.
INTRODUCTION:Serum albumin reflects nutritional status and allostatic load, making it useful for surgical risk assessment in undernourished populations. Chronic socioeconomic and environmental stress can cause weathering, an accelerated decline in physiological reserve that may increase surgical vulnerability in disadvantaged patients. We aimed to define a locally optimized preoperative serum albumin cutoff for predicting 30-d postoperative mortality in our population. METHODS:We performed a secondary analysis of ACS-NSQIP data (2019-2023) from a tertiary-care center in Karachi, Pakistan. Adults undergoing major elective procedures with available preoperative albumin were included. Multivariable Cox regression assessed the association between albumin and 30-d mortality after adjustment for sex, age, body mass index, diabetes, smoking, immunosuppression, and hypertension. Kaplan-Meier curves were generated using the identified albumin cutoff and compared with the log-rank test. RESULTS:Among 1019 patients (50.1% female), the optimal preoperative albumin cutoff for 30-d mortality was 3.55 g/dL (area under the curve: 0.82; sensitivity 70%, specificity 79%). Using this threshold, 248 patients (24.3%) had albumin <3.55 g/dL. In the fully adjusted model, low albumin was independently associated with 30-d mortality (hazard ratio: 2.83, 95% confidence interval: 1.50-5.33), whereas other covariates were not statistically significant. Kaplan-Meier analysis showed significantly lower survival in the albumin <3.55 g/dL group (log-rank P < 0.01). Albumin performed poorly for predicting any postoperative complication (area under the curve: 0.65). CONCLUSIONS:Preoperative hypoalbuminemia was independently associated with an increased hazard of 30-d postoperative mortality. A locally derived cutoff of 3.55 g/dL may help identify nutritionally vulnerable patients and support elective delay and targeted nutritional optimization.
INTRODUCTION:Thyroid nodules are common, with malignancy identified in 5%-15% of cases. Ultrasound-based Thyroid Imaging Reporting and Data System (TI-RADS) and fine-needle aspiration biopsy-derived Bethesda classifications are central to risk stratification and clinical decision-making. However, both systems were developed without explicit consideration of racial diversity, raising concerns regarding their generalizability. Given known racial disparities in thyroid cancer presentation and outcomes, this study evaluated whether the diagnostic performance of TI-RADS and Bethesda varies across racial groups. METHODS:A retrospective cohort study was conducted at a single quaternary academic center. Adult patients who underwent thyroidectomy with available final pathology and preoperative TI-RADS scoring, Bethesda classification, or both were included. Test-positive thresholds were defined as TI-RADS ≥4 and Bethesda III-VI. Sensitivity and specificity were calculated using surgical histopathology as the reference standard. Diagnostic performance was stratified by race, and chi-square analyses were performed. Receiver operating characteristic curves were generated to compare overall discriminatory ability. RESULTS:Of 512 patients, 64.7% were White, 32.4% Black, and 2.9% other racial/ethnic groups. Malignancy was identified in 31.4%. TI-RADS sensitivity was 73.2% overall and did not differ significantly by race (76.9% Black versus 68.8% White; P = 0.432). Specificity was 49.0% overall and was higher in Black patients (56.8%) than White patients (45.7%), although this difference was not statistically significant (P = 0.093). Bethesda demonstrated higher overall sensitivity (89.3%) and specificity (60.6%), with similar sensitivity across groups (89.5% Black versus 88.1% White; P = 0.823). Specificity was marginally higher in Black patients (68.5%) than White patients (56.6%), although this difference was also not statistically significant (P = 0.056). Receiver operating characteristic analysis showed superior discriminatory performance of Bethesda compared with TI-RADS. CONCLUSIONS:TI-RADS exhibited moderate sensitivity and low specificity, whereas Bethesda demonstrated stronger diagnostic accuracy. Importantly, performance did not significantly differ by race for either classification system, supporting their applicability in this Southern US cohort. The consistently higher specificity observed among Black patients, although not statistically significant, warrants further investigation. These findings highlight opportunities for further refinement, including biology-informed threshold adjustments and prospective validation in more diverse cohorts, to ensure continued equitable diagnostic performance.
Introduction The Liver Donor Risk Index (LDRI) has long served as the principal tool for quantifying donor risk in liver transplantation, integrating donor and graft characteristics to estimate graft failure. However, shifts in donor demographics and the widespread adoption of machine perfusion technologies may have reduced its relevance to contemporary practice. We therefore evaluated the contemporary predictive performance of the LDRI for 90-d graft survival. Methods Using the UNOS registry, we examined 49,220 liver transplant recipients across three time periods, replicating the methodology from the original LDRI study to assess whether donor characteristics from the modern transplant era (2018-2024) retained predictive value for 90-d graft survival. Results In modern transplant eras, graft survival differences across LDRI categories were minimal, and multiple modeling strategies using over 250 donor features failed to identify strong predictors of 90-d graft failure, with uniformly limited accuracy and generalizability (AUC = 0.58). Conclusions Our findings demonstrate that 90-d graft failure is influenced less by donor attributes alone and more by the dynamic interplay between donor, recipient, and procedural factors. This study further calls into question the ongoing relevance of donor-based risk models in contemporary liver transplantation.
Introduction Health information technology (HIT) tools intended to remotely monitor patients’ symptoms using electronic patient-reported outcomes (ePROs) can improve clinical outcomes; however, successful design requires meeting the unique needs of complex end user groups. Therefore, we applied a user-centered design approach to iteratively evaluate and inform improvements to an ePRO system designed for postdischarge thoracic surgery care, incorporating perspectives of patient, caregiver, and provider end users. Methods We purposively recruited a targeted sample of thoracic surgery patients, their caregivers, and providers to participate in field observations and semi-structured interviews; patients additionally completed the System Usability Scale and Post-Study System Usability Questionnaire to assess usability. The research team synthesized data through iterative modeling, which was subsequently validated through a mixed end user focus group. Data were analyzed using descriptive statistics and thematic content analysis guided by the Systems Approach to Health Care Delivery and Lean Six Sigma 6 Ms frameworks. Results A total of 16 end users participated, including patients (n = 4), caregivers (n = 2), and 10 providers representing distinct segmented user groups of nurses (n = 4) and surgeons (n = 6). Emergent themes centered on user expectations, personalization, relationships, communication, and accessibility. Participants also highlighted the survey's brevity, responsiveness of the care team, opportunities to strengthen patient and provider training, the need for clearer communication regarding ePRO use, and preferences for more contextualized alerts. Findings informed specific recommendations for system optimization. Conclusions The user-centered design approach generated rich insights into end user experiences, expectations, and interactions with the ePRO system. Future design efforts should focus on improvements that better support the diverse needs, workflows, and contexts of complex end users.
Introduction We sought to determine the extent of receipt of preventive care and health promotion in a modern cohort of early-stage breast cancer survivors within a single breast program. Materials and methods We enrolled patients with stage I-II ER + or PR+, HER2/neu-breast cancer diagnosed within the past 5 years from a single program (January-March 2020). Receipt of preventive care was assessed via electronic health record abstraction. Perceived receipt of health promotion counseling was evaluated via survey. Results Our final cohort (n = 94) was mostly White females (95%) with stage I disease (73%) who were a mean of 2.5 years from diagnosis (SD = 1.3). Of 58 survivors with a primary care provider within the participating health system, the majority received preventive care services such as colorectal cancer screening (76%), pneumococcal (92%) and flu (76%) vaccinations, and mammograms (100%). Many survivors in the overall cohort did not perceive recent discussions with their healthcare providers about specific health promotion topics such as: “How much or what kind of exercise you get” (41%) and “How much or what kinds of food you eat” (18%). Conclusions In this cohort of early-stage breast cancer survivors, documented receipt of preventive care was high (>75%). However, survivors perceived limited discussions with providers about specific health promotion topics. Our findings support the need to measure, standardize, and incentivize health promotion for breast cancer survivors to improve survivor longevity and quality of life.
INTRODUCTION:Open-window thoracostomy is a recognized treatment for postresection empyema, especially when complicated by bronchopleural fistula (BPF). However, the necessity of definitive closure surgery remains unclear. METHODS:We retrospectively analyzed 24 patients who developed empyema after anatomical lung resection and underwent open-window thoracostomy at our institution between April 2010 and March 2024. We evaluated factors associated with spontaneous closure of BPF and the empyema cavity, as well as the clinical indications for definitive surgical closure. RESULTS:BPF was present in 17 of the 24 patients (71%). Among them, 10 experienced spontaneous fistula closure, while two required surgical closure. Smaller fistula size (<5 mm) was significantly associated with spontaneous closure, whereas the absence of contralateral aspiration pneumonia showed a trend toward spontaneous closure but did not reach statistical significance. Definitive closure of the empyema cavity was performed in 11 patients and was more common in those with higher body mass index and a better general condition. Of the 13 patients who did not undergo definitive closure, the cavity closed spontaneously in five. Notably, negative-pressure wound therapy was significantly associated with spontaneous cavity closure (80% versus 12.5%, P = 0.032). Patients who had undergone pneumonectomy failed to achieve cavity closure within 2 y, whereas 87.5% of those who had undergone lesser resections did. CONCLUSIONS:Spontaneous closure of BPF and the empyema cavity is possible, particularly in patients with small fistulas and no history of pneumonectomy. Negative-pressure wound therapy appears beneficial in promoting spontaneous healing, supporting a tailored, patient-specific approach to managing postresection empyema.
INTRODUCTION:The association between the platelet-to-red blood cell (PLT:RBC) ratio and clinical outcomes in massively transfused trauma patients within the intensive care unit (ICU) remains unclear. This study aimed to evaluate the association. METHODS:This retrospective cohort study utilized the MIMIC-IV version 3.1 database. Trauma patients aged ≥16 y who were admitted to the ICU at hospital admission and received massive transfusion (total volume of red blood cells and plasma ≥2000 mL) within 24 h of ICU admission were included. These patients were stratified into the low-ratio (<1:5; n = 111) group and the high-ratio (≥1:5; n = 57) group based on the 24-h PLT:RBC volume ratio. The primary outcome was 28-d all-cause mortality. The secondary outcomes included blood product consumption, 28-d ICU-free and hospital-free days, and a composite adverse outcome (severe acute kidney injury, sepsis, or prolonged mechanical ventilation). RESULTS:A total of 168 patients were included. After adjustment, the high-ratio (PLT:RBC) transfusion strategy was not significantly associated with 28-d mortality (adjusted odds ratio, 1.59; P = 0.253), the composite adverse outcome (adjusted odds ratio, 1.62; P = 0.339), 28-d ICU-free days (adjusted mean difference, -2.14; P = 0.215), or 28-d hospital-free days (adjusted mean difference, -1.78; P = 0.164). Nevertheless, the high-ratio (PLT:RBC) transfusion strategy was significantly associated with a 33% reduction in total RBC consumption (adjusted ratio, 0.67; P < 0.001) and a 20% reduction in total blood product consumption during the ICU stay (adjusted ratio, 0.80; P = 0.037). CONCLUSIONS:The high PLT:RBC ratio transfusion strategy used in massively transfused trauma patients may be associated with lower blood product consumption but is not significantly associated with mortality or adverse outcomes.
INTRODUCTION:Burn injuries remain a leading cause of morbidity and mortality in low- and middle-income countries, particularly in sub-Saharan Africa. Management of severe burns often requires early surgical debridement and skin grafting to reduce infection risk and promote wound healing. This study aimed to evaluate trends in burn mortality at Kamuzu Central Hospital (KCH) from 2011 to 2024 and assess the role of surgical intervention on patient outcomes. METHODS:We analyzed a database of patients admitted to the KCH burn unit in Lilongwe, Malawi. We conducted bivariate analyses to evaluate associations between surgical intervention and in-hospital mortality, followed by logistic regression to determine the independent contribution of surgical intervention on mortality after burn injury. RESULTS:There was no significant change in burn mortality rates over the study period. However, surgical intervention was independently associated with decreased odds of death (odds ratio: 0.20, 95% confidence interval [CI] 0.11-0.36, P < 0.001), whereas increasing total body surface area was strongly associated with increased mortality (odds ratio: 1.09 per 1% increase, P < 0.001). Only a small proportion of patients underwent surgical intervention despite its protective role. CONCLUSIONS:Burn mortality at KCH has remained essentially unchanged over the past decade. Surgical intervention is strongly protective but remains underutilized. Expanding access to early surgical debridement and grafting may be a critical step toward reducing burn mortality in resource-limited settings.
INTRODUCTION:After Arkansas repealed its universal motorcycle helmet law in 1997, helmet use decreased and motorcycle-related injuries and fatalities increased. Long-term clinical and population-level impacts of this policy change remain incompletely characterized. This study integrates statewide crash and fatality data with trauma center data to evaluate trends in helmet use, injury severity, and mortality at scene and hospitalization. METHODS:We retrospectively reviewed motorcycle-related admissions and emergency department deaths at the state's only adult level I trauma center from 2004 to 2023 across three periods: 2004-2006, 2013-2015, and 2021-2023. Demographics, helmet use, injury severity, and outcomes were assessed. Logistic regression evaluated associations between helmet use, severe head injury (Abbreviated Injury Scale ≥3), and inhospital mortality. Fatality data were obtained from the National Highway Traffic Safety Administration, and crash-level data (2015-2023) were obtained from the State Department of Transportation. RESULTS:Among 1104 trauma admissions, annual admissions nearly tripled over time, with nonhelmeted riders representing 64%-72%. Helmet use was independently associated with lower odds of severe head injury (odds ratio 0.48, P < 0.001). Nonhelmeted riders had higher on-scene fatality risk (relative risk 1.21). Severe head injuries increased and were strong predictors of inhospital mortality. Population-adjusted motorcycle fatality rates rose from 2.34 to 3.18 per 100,000 residents by 2021-2023. CONCLUSIONS:Motorcycle fatalities and severe head injuries increased during the postrepeal period and were associated with helmet nonuse and severe head trauma. Clinical and statewide data show consistent associations among helmet nonuse, severe head injury, and prehospital and in-hospital mortality, highlighting helmet use as a target for injury prevention policy.
INTRODUCTION:Preoperative imaging before ostomy reversal in trauma patients is understudied. We hypothesized that imaging would infrequently identify clinically actionable findings and that routine imaging would represent a less cost-effective strategy. METHODS:Trauma patients with ostomy creation at a Level 1 trauma center (2017-2024) were identified. Associations between injury patterns, imaging, intraoperative factors, and surgical outcomes were analyzed using univariable and multivariable methods. A decision analytic model was developed to evaluate the cost-effectiveness of routine imaging before ostomy reversal. RESULTS:Of 280 patients with intestinal injuries, 70 required ostomies, and 55 underwent reversal. Preoperative imaging was performed in 36 (65%) patients, identifying rectal narrowing in two (3.6%). Loop ostomy (odds ratio 5.7, P = 0.02) was associated with rectal contrast studies. Increasing age (odds ratio 1.2, P = 0.008) was associated with colonoscopy. CONCLUSIONS:Routine preoperative imaging was not associated with documented changes in surgical management among trauma patients undergoing ostomy reversal.
Introduction We sought to evaluate the representation of different skin tones depicted in images of anorectal pathology found in colorectal surgery textbooks. Methods Nonillustrated photographic images depicting anorectal pathology were identified and analyzed from colorectal surgery textbooks. Images were classified based on category and pathology. The Fitzpatrick skin phenotype scale and constitutive skin color scale were used to evaluate each image. Fitzpatrick phototypes I-III represented skin of noncolor and phototypes IV-VI represented skin of color. The skin tone distribution was assessed over time and compared to the distribution of the general population. Results A total of 744 images from 13 textbooks were included. Textbooks were published from 2003 to 2022. Images were categorized as: diagnostic (78%), surgical (18.7%), postoperative (2.6%), or anatomic (0.7%). There were 466 (62.6%) images depicting benign/noninfectious pathology, 181 (24.4%) of infectious pathology, and 97 (13%) of malignant pathology. Based on the Fitzpatrick scale, most (84.7%) images depicted skin of noncolor. Similarly, using the constitutive scale, 86.9% of images depicted “light or fair” skin tones and only 13.1% depicted “medium or dark” skin tones. Across all pathological categories, noncolor skin was the most prevalent skin tone depicted. Compared to the distribution of skin tones in the general population, the proportion of textbook images depicting skin of color was significantly (P = 0.0001) decreased. Over time, the proportion of images depicting noncolor skin has not significantly changed. Conclusions Across all image categories and diagnoses, anorectal pathology is significantly underrepresented on skin of color in colorectal surgery textbook images.
INTRODUCTION:Intrahepatic cholangiocarcinoma (ICC) is a highly aggressive malignancy with limited responsiveness to chemotherapy. RAD51, a key component of homologous recombination repair, has been implicated in tumor progression and therapeutic resistance in several cancers; however, its clinical and biological role in ICC is unclear. METHODS:RAD51 expression was evaluated by immunohistochemistry in 96 patients having upfront surgery for ICC. Clinicopathological correlations and survival outcomes were analyzed. Functional studies were conducted in the ICC cell lines, HuCCT1 and TKKK, using small interfering RNA-mediated RAD51 knockdown and RAD51 inhibitor IBR2. RESULTS:High nuclear RAD51 expression was detected in 60 cases (62.5%). Patients with high RAD51 expression exhibited larger tumor sizes and more frequent lymph node metastases than those with low RAD51 expression. Kaplan-Meier analysis revealed that high RAD51 expression was significantly associated with worse disease-free survival and overall survival. Multivariate analysis confirmed RAD51 as an independent prognostic factor of poor survival. In vitro, RAD51 knockdown reduced ICC cell proliferation without affecting migration or invasion. IBR2-mediated pharmacological inhibition of RAD51 reduced cell proliferation with induced G2-phase arrest. Cisplatin treatment increased RAD51 messenger RNA expression and enhanced nuclear RAD51 foci colocalizing with γH2AX, indicating compensatory homologous recombination repair activation in response to DNA damage. Even low doses of IBR2 promoted cisplatin-induced cytotoxicity, increased lactate dehydrogenase release, and augmented apoptosis. CONCLUSIONS:RAD51 expression predicts poor prognosis after surgery for patients with ICC and functionally promotes ICC cell survival. Therapeutic targeting of RAD51 may enhance the antitumor efficacy of cisplatin and represents a promising strategy to improve prognosis.
Introduction Training residents in pediatric laparoscopic surgery remains challenging due to the technical learning curve. Laparoscopic pediatric inguinal hernia repair is a standardized procedure with reproducible steps that may serve as an ideal operation for simulation-based surgical training. Methods Pediatric surgeons within the Kaiser Permanente Southern California system transitioned to a percutaneous laparoscopic approach for pediatric inguinal hernia repair in 2021. During this transition, residents were trained using a simulation-based curriculum followed by supervised operative participation. A retrospective review compared outcomes between cases performed by attending surgeons alone and those involving residents. Results From 2020 to 2025, 784 patients underwent laparoscopic pediatric inguinal hernia repair. A total of 307 cases involved resident participation, and 477 were performed by attending surgeons alone. Patient age did not differ between groups (59.9 versus 54.8 mo, P = 0.193). Operative duration was longer in cases involving residents (38.2 versus 31.2 min, P < 0.001). Thirty-d emergency department visits occurred in 2.0% of patients and were similar between groups (0.9% versus 2.7%, P = 0.12), while 90-d emergency department visits were lower in the resident cohort (1.8% versus 4.5%, P = 0.049). However, hernia recurrence requiring reoperation at ≥2 y of follow-up was higher in the resident cohort (6.4% versus 1.8%, P = 0.026). Conclusions Resident participation in laparoscopic pediatric inguinal hernia repair was associated with longer operative duration and higher long-term hernia recurrence, while short-term postoperative outcomes remained comparable. These findings support the feasibility of resident participation in this standardized procedure under direct supervision and highlight the importance of continued technical refinement during surgical training.
Introduction To better understand baseline prescribing patterns before the release of the American Academy of Pediatrics (AAP)'s 2024 clinical guidelines on opioid prescribing, we evaluated the degree to which discharge pain management practices following minimally invasive repair of pectus excavatum (MIRPE) aligned with AAP's recommendations across 10 children's hospitals. Methods Patients aged ≤21 y who underwent MIRPE (January 2022 to October 2023) were retrospectively reviewed. Those who underwent MIRPE for recurrent disease or underwent concurrent procedure(s) at the time of repair were excluded. Descriptive statistics were used to summarize findings. Results A total of 528 patients were analyzed. The median preoperative Haller Index was 4.5 (interquartile range [IQR] 3.8, 5.7) and Correction Index was 33.0% (IQR 26.2%, 43.2%). One bar was placed in 50% of patients, two bars in 47.5% of patients, and three bars in 2.5% of patients. Cryoablation was used in 90% of patients, and 3.6% received subcutaneous pain pumps. The median hospital length of stay was 1 d (IQR 1.0, 2.0). Nearly all patients were discharged with nonopioid analgesics: acetaminophen (98.9%), nonsteroidal anti-inflammatory drugs (97.9%); 31.8% were prescribed gabapentin. Opioids were prescribed for 494 (93.6%) patients, with 95.5% of prescriptions written for fewer than 5 d. No patients received tramadol, codeine, opioid monotherapy, or long-acting opioids. Naloxone was prescribed for 37 (7.0%) patients. Co-prescription of opioids with benzodiazepines and/or muscle relaxants occurred in 79.7% of cases. Conclusions Baseline discharge analgesic prescribing practices following MIRPE only partially aligned with AAP's guidelines. Opportunities for improvement include prescribing naloxone with opioids and reduction in co-prescription of sedating medications.
Introduction Robotic surgery has expanded rapidly in the United States despite high financial commitments of a robotic surgery program. Factors that drive uneven robotic surgery adoption has not been adequately explored at the populational level. Methods A retrospective analysis was performed using the National Cancer Database to evaluate facility-level adoption of robotic colorectal surgery. Facilities were stratified by the timing of the first robotic colorectal case into adoption quartiles (1st: earliest to 4th: latest) and nonadopters. A multivariable ordinal logistic regression model with mixed-methods approach with clustering at the facility level was performed to evaluate the association between the timing of robotic surgery adoption and region, institution-type, and patient socioeconomic demographic variables. Results A total of 1182 facilities were identified as robotic surgery adopters between 2010 and 2021. Early adopting facilities were more likely to be academic facilities (OR 0.34, 95% CI: 0.24-0.47) that treated high-income patients (OR 0.81, 95% CI: 0.70-0.94) with access to insurance (OR 0.71, 95% CI: 0.61-0.81). Early adopting facilities were less likely to treat patients from urban (OR 1.41, 95% CI: 1.18-1.69) and rural regions (OR 1.34, 95% CI: 1.01-1.78) compared to metropolitan areas. Conclusions Robotic colorectal surgery adoption is influenced by academic status of the facility and socioeconomic make-up of patients treated at the facility. Ensuring equitable access to advanced surgical technology remains an essential systems-level priority to reduce differences in surgical care delivery.
