The pediatric melanoma population is not well described, and current guidelines for their management are not well defined. Our study aims to identify this population, treatment modalities, and outcomes using a national population-based database. We reviewed the Surveillance, Epidemiology, and End Results database (2004–2008). Patients ≤21 years old with melanoma were included and grouped into ≤12 years of age, 13 to 18 years, and 19 to 21 years. Clinical characteristics were analyzed across the groups. A total of 1255 patients were included: 52.7 per cent were 19 to 21 years of age, 36.3 per cent were 13 to 18 years of age, and 11.0 per cent were ≤12 years of age. The 19- to 21-year-olds had the highest proportion of stage I (50.5%) versus ≤12 years of age (31.9%); the ≤12-year-olds had the highest proportion of stage IV (3.6%) versus 19 to 21 years of age (0.9%), P < 0.001. The 19- to 21-year-olds had the highest proportion receiving wide local excisions only (34.8%) versus ≤12 years of age (26.4%); the ≤12-year-olds had the highest proportion of patients without any surgeries (16.0%) versus 13 to 18 years of age (9.4%), P = 0.169. On adjusted analysis, the 19- to 21-year-olds had worse survival compared with ≤12 years of age (hazard ratio: 5.26, P = 0.017, 95% confidence interval 1.34–20.65). Disparities were found in the ≤12-year-old melanoma population, as they had later stage melanomas, less invasive surgery, and lower survival. Clearer prognostic factors are needed to better elucidate their management.

Background: Following traumatic infrapopliteal arterial injury, salvageability of the leg is often attributed to injury-related variables. We investigated factors influencing amputation. Method: The United States’ National Trauma Data Bank was retrospectively examined identifying subjects aged ≥ 18 with tibial arterial injuries. Demographic, injury-related, co-morbid, and other variables were analyzed. Univariate and multivariable analyses determined predictors of lower extremity amputation. Results: 1921 subjects were included, mean age 38 years, 82% male, 65% had blunt injury, 58% white and 22% black. Insurance status: Private 24%, Self-Pay 20%, Medicare/Medicaid 17%, Other 14%, and Not-billed 1%. Average stay (days): ICU (4), hospital (15). Mortality was 2.5%. 13.6% had lower extremity amputation (10.6% below knee) and independent predictors of amputation were: male gender (OR:1.66,CI:1.11-2.34, P=0.012), Injury Severity Score (OR:1.62,CI:1.02-2.38, P<0.001), insurance status: Self-Pay (OR:1.76,CI:1.11-2.79, P=0.016), Medicare/Medicaid (OR:1.66, CI:1.03-2.67, P=0.039), Other (OR:1.61,CI:1.01-2.58, P=0.047), Notbilled (OR:1.52,CI:1.01-2.28, P=0.043). Conclusion: Insurance type is a major determinant of lower extremity amputation following traumatic infrapopliteal arterial injury. Keywords: Lower extremity amputation, arterial trauma, insurance

INTRODUCTION:Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections account for most hepatocellular carcinoma (HCC) and subsequent liver transplant cases. Racial/ethnic disparities exist in access to liver transplantation and post-transplantation survival, and we sought to compare and explore potential disparities in HBV and HCV-related liver transplant populations.METHOD:The Nationwide Inpatient Sample database was used (2001 to 2010).RESULTS:In this study, 2269 liver transplant recipients were included: 56% HCV, 6% HBV, and 37% non-HV. HBV and HCV patients were mostly Asian/Pacific Islander (API) and white, respectively. Within HBV transplant recipients, the mean age was youngest in black patients (P = .02); variation of mean age was not seen within HCV patients. Regarding the transplant recipients' income and insurance, most API and white patients were in the highest income quartile, whereas most black and Hispanic patients were in the lowest income group (P < .001). The most common form of payer across all racial/ethnic groupings was private insurance (P < .001). The mean length of hospitalization was longest in Hispanic patients (P = .008); they had a significantly longer stay compared with white patients (P = .02). The liver transplantations were mostly performed in teaching hospitals, located in urban areas in the West region of the United States (P < .001).CONCLUSION:Differences were found in the HBV and HCV-associated liver transplant populations. More work needs to be done to elucidate disparities regarding black and Hispanic liver transplant recipients as they receive transplants at younger mean ages, are in lower income quartiles, and have longer lengths of hospitalization compared with other racial/ethnic groupings.

BACKGROUND: Trauma associated splenic artery aneurysm (SAA) is potentially life threatening and infrequently studied. We evaluated the subject using a large trauma database.METHODS: The National Trauma Data Bank (2002 to 2006) was queried. All patients aged greater than or equal to 18 years with a primary diagnosis of SAA (International Classification of Diseases: Ninth Revision code 442.83) were identified. Data on demographics, injury severity, pre-existing co-morbidities, surgical interventions, complications, and mortality were analyzed.RESULTS: One hundred twenty-four patients were included with a mean age of 40 +/- 13 years and 72% were male. Mean Injury Severity Score was 24 +/- 12. All patients suffered blunt trauma, and 5% of the patients (n = 6) had systolic blood pressure less than 90 mm Hg on arrival. The most frequent interventions were surgical ligation of aneurysm (45%), bronchoscopy (35%), endovascular procedures (27%), splenectomy (27%), and thoracostomy tube (25%). About 1.7% developed pulmonary collapse. Mean length of stay was 13 days and mortality was 1.6%.CONCLUSIONS: Trauma associated SAA has low mortality and most patients require surgical intervention. Pulmonary dysfunction and invasive pulmonary procedures are frequent despite low rate of chest injuries possibly due to anatomic proximity of lung and spleen. (C) 2016 Elsevier Inc. All rights reserved.

Background: Despite previous single-institution studies showing that lower extremity arterial reconstruction ( LEAR) in octogenarians and older patients may be undertaken with acceptable postoperative morbidity and mortality, there continues to be significant reluctance, in the vascular surgical community, to undertaking these complex revascularization procedures in this very elderly population. We undertook this study in an effort to determine the outcomes of LEAR in octogenarians and older patients on a national level.Methods: The American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify all patients who underwent LEAR between January 1, 2005 and December 31, 2009. Patient demographics and presenting comorbidities were recorded, and multivariate analyses were performed to compare outcomes in patients 80 and older to those in younger patients.Results: There were 19,028 patients who underwent open infrainguinal LEAR during this time period. Patients >= 80 comprised 18% ( 3,486 patients), and patients < 80 years comprised 82% ( 15,542 patients). Multivariate analysis demonstrated that patients aged >= 80 years had an increased likelihood of mortality ( odds ratio [ OR] 1.79; 95% confidence interval [ CI] 1.42-2.26), cardiovascular ( OR, 1.46; 95% CI, 1.12-1.89), respiratory ( OR, 1.37; 95% CI, 1.12-1.67), and renal ( OR, 1.57; 95% CI, 1.27-1.95) complications. There was, however, no significant difference in the likelihood of graft failure ( OR, 1.04; 95% CI, 0.86-1.27), wound infection ( OR, 0.92; 95% CI, 0.79-1.06), or major amputation ( OR, 0.59; 95% CI, 0.13-2.74) between these 2 groups.Conclusions: LEAR in octogenarians is associated with an increased risk of postoperative morbidity and mortality but no increased risk of wound infection, amputation, or graft failure.

Background: HIV-infected patients are at an increased risk for accelerated vascular disease. Abnormal endothelial function and aneurysmal dilation of the large arteries have been described; however, data is lacking on the outcomes of HIV-infected patients undergoing abdominal aortic aneurysm (AAA) repair on a national level. Methods: This study is a retrospective analysis of hospital discharge data using the Nationwide Inpatient Sample Database from 2001 – 2009. HIV-infected patients undergoing abdominal aortic aneurysm repair were included. Results: From 2001 to 2009, we identified 23 HIV-infected patients who underwent abdominal aortic aneurysm repair, with a mean age of 56 (±12). Of these, 14 (61%) had open repair, while 9 (39%) had endovascular repair; four of the open repair patients presented with ruptured AAA. There were two postoperative deaths after open repair (9% mortality), 1 death from the ruptured AAA open repair group and 1 death from the non-ruptured open repair group. Three cases in the ruptured open group had sepsis, and one patient had both respiratory and graft complications. In the non-ruptured open group, one patient developed sepsis and cardiac complications. There were no mortalities in the endovascular group, although 1 patient developed sepsis and 2 had cardiopulmonary complications. Conclusions: Perioperative outcomes appear to be similar for HIV positive patients who undergo open and endovascular AAA repair compared to HIV negative patients. Keywords: abdominal aortic aneurysm, repair, HIV

BACKGROUND:Previous reports have noted that obese patients undergoing lower extremity arterial reconstruction have higher complication rates compared with nonobese patients. We evaluated the effect of obesity on outcomes following open infrainguinal arterial reconstruction on a national level.METHODS:A query of the American College of Surgeons' National Surgical Quality Improvement Program Database was conducted to identify all adult patients who underwent open infrainguinal lower extremity arterial reconstruction from 2005 to 2009. Postoperative outcomes were analyzed in different body mass index groups.RESULTS:Obese and morbidly obese patients had a higher risk of wound infection when compared with normal weight patients (odds ratios 2.1 and 2.7, P < .05). Obese patients had a lower mortality when compared with normal weight patients (odds ratio .83, P < .05).CONCLUSIONS:Obesity was associated with an increase in wound infection after open lower extremity arterial reconstruction. Obesity, but not morbid obesity, was associated with decreased mortality.

Background Patients with pre-injury coagulopathy have worse outcomes than those without coagulopathy. This article investigated the risk-adjusted effect of pre-injury coagulopathy on outcomes after splenic injuries. Methods Review of the National Trauma Data Bank from 2007 to 2010 comparing mortality and complications between splenic injury patients with and without a pre-injury bleeding disorder. Results Of 58,896 patients, 2% had a bleeding disorder. Coagulopathic patients had higher odds of mortality (odds ratio, 1.3), sepsis (odds ratio, 2.0), acute respiratory distress syndrome (odds ratio, 2.6), acute renal failure (odds ratio, 1.5), cardiac arrest (odds ratio, 1.5), and overall complications (odds ratio, 2.4). The higher odds of myocardial infarction did not achieve statistical significance (odds ratio, 1.6). Conclusions Pre-injury coagulopathy in patients with splenic injury has a negative impact on cardiac arrest, sepsis, acute respiratory distress syndrome, acute renal failure, and mortality. The higher likelihood of myocardial infarction did not reach statistical significance.

Introduction: Studies have quantified the annual cost of acute pancreatitis, but to date there is limited data on the impact of comorbidities on the cost of hospitalizations among patients with acute pancreatitis Methods: An analysis of the 2005 to 2010 Nationwide Inpatient Sample (NIS) database was conducted. Using ICD9 code 577.0 we identified adult (aged ≥ 18 years) patients with primary diagnosis of acute pancreatitis. We excluded patients with secondary diagnosis of chronic pancreatitis (ICD9 code 577.1). We also excluded those age 79 years. The most frequent comorbidities in those hospitalized for acute pancreatitis were obtained. Primary outcome was cost which was estimated by multiplying total charges with hospital-specific cost-to-charge ratios. All costs were adjusted for inflation by converting to 2010 US dollars using appropriate consumer price index. Discharge level weights were applied to the data. Generalized linear models were used to estimate the mean cost of hospitalization by number of comorbidities. We subsequently estimated the added unadjusted and adjusted mean cost of hospitalization for the presence versus absence of each of the listed comorbidity. Our model adjusted for patient level factors, hospital factors, year of admission, and geographic price index. Results: Overall, 329,717 patients met all criteria. The most frequent comorbidities were hypertension 148,053 (45%), alcohol abuse 80,017 (24%), uncomplicated diabetes mellitus 66,627 (20%) and anemia 44,356(13%). Most patients had 3 or more comorbidities (n=133,104 (40%)), while 77,578 (24%), 69,986 (21%) and 49,049 (15%) patients had two, one, and no comorbidity, respectively. The mean adjusted hospitalization cost was significantly higher for patients with three or more comorbidities $9568($9464, $9672) versus $ 8,341 ($8,235, $8,448) for patients without any comorbidity. Of the top most frequent comorbidity, the presence of Anemia had the highest estimated cost. When comparing the presence versus the absence of specific comorbidities, Alcohol disorder was associated with a significantly lower cost of hospitalization among patients with acute pancreatitis(Table). Conclusion: Using a nationally representative sample, we demonstrated differential cost of hospitalization for acute pancreatitis by specific comorbidity and increasing cost of hospitalization as the number of comorbidities increased.More research to further investigate this finding is needed.Table 1: Impact Of Comorbidity On Adjusted Cost Of Hospitalization Of Acute Pancreatitis: By Most Frequent Comorbidities

BACKGROUND:Open femoral fractures are common; however, many factors may affect treatment protocol. We aim to assess any racial/ethnic or sex disparities associated with the definitive fixation of open femoral fractures.METHODS:ICD-9 codes from the National Trauma Data Bank (2007 to 2010) for patients greater than or equal to 18 years with open femoral fractures who underwent operative management at level I or II trauma centers were identified and analyzed.RESULTS:Of the 9,406 cases, the majority were White (61%), men (73%), and aged between 25 and 44 years (41%). The odds of definitive fixation after hospital day 2 (odds ratio [OR] .96, 95% confidence interval [CI] .82 to 1.09, P = .53) or any complication (OR .96, 95% CI .79 to 1.15, P = .69) were not associated with race/ethnicity. Men were 17% less likely to have surgery after hospital day 2 (OR .83, 95% CI .78 to .96, P < .001), and 18% more likely to have a complication (OR 1.18, 95% CI 1.03 to 1.35, P = .02).CONCLUSIONS:There are no racial/ethnic disparities associated with the timing of definitive fixation. Men are more likely to undergo fixation earlier than women; however, they are more likely to have a complication. Fixation within the first 2 hospital days may decrease complications.

Background This study seeks to investigate the outcomes of laparoscopic procedures in patients with previous open abdominal surgery. Methods Using data from the National Surgical Quality Improvement Program (2005 to 2009), we identified patients who had undergone laparoscopic cholecystectomy, Nissen fundoplication, Heller myotomy, splenectomy, Roux-en-Y, sleeve gastrectomy, gastric band, appendectomy, or colectomy. Patients were then classified as to whether adhesiolysis (AD) was also carried out. Bivariate and multivariate analysis was used to compare groups. Results A total of 162,415 patients met our inclusion criteria, comprising 4,501 (3%) in the AD group and 157,913 (97%) in the nonadhesiolysis (NAD) group. Patient who had received lysis of adhesion were older, had 41% higher odds of overall complications, 17% higher adjusted mean lysis of adhesion (P < .001), and 26% higher adjusted mean operation duration (P < .001). Conclusions A history of previous open abdominal surgery increases the potential complication rate and hospital length of stay during subsequent laparoscopic surgery. The extent of this relationship deserves further investigation.

OBJECTIVE:To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery.BACKGROUND:Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist.METHODS:Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses.RESULTS:A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565-$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures.CONCLUSIONS:Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs.

IMPORTANCE There is growing evidence in support of performing early laparoscopic cholecystectomy (LC) for acute cholecystitis. However, the definition of early LC varies from 0 through 10 days depending on the research protocol. The optimum time to perform early LC is still unclear. OBJECTIVES To determine whether outcomes after early LC for acute cholecystitis vary depending on time from presentation to surgery and to determine the optimum time to perform LC for acute cholecystitis. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective review of prospectively collected data from the Nationwide Inpatient Sample (NIS) for 2005 through 2009. The population-based sample included 95,523 adults (18 years and older) who underwent LC within 10 days of presentation for acute cholecystitis. INTERVENTIONS Patients were categorized and analyzed in 2 ways based on length of time from presentation to surgery. First, patients were categorized into 3 groups: 0 through 1 day, 2 through 5 days, and 6 through 10 days. Second, we compared outcomes for each incremental preoperative day (days 0-5). MAIN OUTCOMES AND MEASURES Outcomes of interest were mortality, length of stay, complications, and cost. Propensity score matching and generalized linear modeling were used. The hypothesis being tested was formulated after data collection was complete. RESULTS A total of 95,523 patients were selected. After matching the 3 groups based on propensity scores, patients who underwent surgery during days 2 through 5 and days 6 through 10 had increasingly worse outcomes when compared with those undergoing surgery on days 0 through 1. The odds of mortality were 1.26 (95% CI, 1.00-1.58) and 1.93 (95% CI, 1.38-2.68), and the odds of postoperative infections were 0.88 (95% CI, 0.69-1.12) and 1.53 (95% CI, 1.05-2.23) for days 2 through 5 and days 6 through 10, respectively. Adjusted mean hospital cost increased from $8974 (days 0-1) to $17,745 (days 6-10). Analysis by each incremental day revealed the optimal time of surgery to be within the first 48 hours of presentation. CONCLUSIONS AND RELEVANCE Laparoscopic cholecystectomy performed within 2 days of presentation of acute cholecystitis yielded the best outcomes and lowest costs. Although causality could not be established, delaying LC was associated with more complications, higher mortality, and higher costs.

BACKGROUND:There are controversial data on the relationship between trauma and body mass index. We investigated this relationship in traumatic hemorrhagic shock.METHODS:The "Glue Grant" database was analyzed, stratifying patients into underweight, normal weight (NW), overweight, Class I obesity, Class II obesity, and Class III obesity. Predictors of mortality and surgical interventions were statistically determined.RESULTS:One thousand nine hundred seventy-six patients were included with no difference in injury severity between groups. Marshall's score was elevated in overweight (5.3 ± 2.7, P = .016), Class I obesity (5.8 ± 2.7, P < .001), Class II obesity (5.9 ± 2.8, P < .001), and Class III obesity (6.3 ± 3.0, P < .001) compared with NW (4.8 ± 2.6). Underweight had higher lactate (4.8 ± 4.2 vs 3.3 ± 2.5, P = .04), were 4 times more likely to die (odds ratio 3.87, confidence interval 2.22 to 6.72), and were more likely to undergo a laparotomy (odds ratio 2.06, confidence interval 1.31 to 3.26) than NW.CONCLUSION:Early assessment of body mass index, with active management of complications in each class, may reduce mortality in traumatic hemorrhagic shock.

BACKGROUND The burden of injury among older patients continues to grow and accounts for a disproportionate number of trauma deaths. We wished to determine if older trauma patients have better outcomes at centers that manage a higher proportion of older trauma patients. METHODS The National Trauma Data Bank years 2007 to 2011 was used. All high-volume Level 1 and Level 2 trauma centers were included. Trauma centers were categorized by the proportion of older patients seen. Adult trauma patients were categorized as older (≥65 years) and younger adults (16–64 years). Coarsened exact matching was used to determine differences in mortality and length of stay between older and younger adults. Risk-adjusted mortality ratios by proportion of older trauma patients seen were analyzed using multivariate logistic regression models and observed-expected ratios. RESULTS A total of 1.9 million patients from 295 centers were included. Older patients accounted for one fourth of trauma visits. Matched analysis revealed that older trauma patients were 4.2 times (95% confidence interval, 3.99–4.50) more likely to die than younger patients. Older patients were 34% less likely to die if they presented at centers treating a high versus low proportion of older trauma (odds ratio, 0.66; 95% confidence interval, 0.54–0.81). These differences were independent of trauma center performance. CONCLUSION Geriatric trauma patients treated at centers that manage a higher proportion of older patients have improved outcomes. This evidence supports the potential advantage of treating older trauma patients at centers specializing in geriatric trauma. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

INTRODUCTION:Trauma patients have greater rates of complications than general surgery patients; however, existing surgical pay-for-performance (P4P) guidelines have yet to be adapted for trauma care. To better understand whether current P4P measures are applicable to trauma, this study used nationally representative data to determine the mortality and attributable costs associated with the presence or absence of both Centers for Medicare and Medicaid Services-recognized complications (urinary tract infections, surgical site infections [SSIs], and pneumonia) and other major trauma-related complications.METHODS:Trauma admissions were extracted from the 2008 National Inpatient Sample using primary ICD-9-CM diagnosis codes (range, 800-905, 910-939, 950-958). Patients aged 18-65 years with a duration of hospital stay of >3 days and isolated complications were included. To account for differences in patient factors, coarsened-exact matching was used to create comparable cohorts of adult patients with and without complications. Multivariable regression was then performed within matched groups to determine differences in cost and mortality, controlling for hospital characteristics and wage index.RESULTS:Of 493,372 trauma patients, 78,156 met inclusion criteria, of whom 24.4% had an isolated complication. Consistent with surgical P4P guidelines, SSI, urinary tract infections, and pneumonia had the greatest incidence (8.0%, 5.2%, and 4.4%, respectively); however, mortality in matched patients with complications was greatest for sepsis (odds ratio [OR], 9.76; 95% CI, 3.84-24.80), myocardial infarction (MI; OR, 4.21; 95% CI, 1.70-10.44) and stroke (OR, 3.02; 95% CI, 1.40-6.52). Excess costs associated with a complication were similarly greatest for sepsis (relative cost, 1.84; 95% CI, 1.57-2.17), followed by acute respiratory distress syndrome (ARDS; relative cost, 1.84; 95% CI, 1.7-1.99) and MI (relative cost, 1.73; 95% CI, 1.51-1.99).CONCLUSION:Consideration of attributable costs and mortality suggest that additional complications have a substantial impact among trauma patients, beyond the conditions used in general surgery P4P guidelines. These aspects of trauma should be prioritized to capture the influence of complications in trauma that the incidence of frequent but less costly conditions overlooks.