Pediatric Hand and Upper Extremity Injuries Presenting to Emergency Departments in the United States: Epidemiology and Health Care–Associated Costs

Background: Upper extremity injuries represent one of the most common pediatric conditions presenting to emergency departments (EDs) in the United States. We aim to describe the epidemiology, trends, and costs of pediatric patients who present to US EDs with upper extremity injuries. Methods: Using the National Emergency Department Sample, we identified all ED encounters by patients aged <18 years associated with a primary diagnosis involving the upper extremity from 2008 to 2012. Patients were divided into 4 groups by age (≤5 years, 6-9 years, 10-13 years, and 14-17 years) and a trauma subgroup. Primary outcomes were prevalence, etiology, and associated charges. Results: In total, 11.7 million ED encounters were identified, and 89.8% had a primary diagnosis involving the upper extremity. Fracture was the most common injury type (28.2%). Dislocations were common in the youngest group (17.7%) but rare in the other 3 (range = 0.8%-1.6%). There were 73.2% of trauma-related visits, most commonly due to falls (29.9%); 96.9% of trauma patients were discharged home from the ED. There were bimodal peaks of incidence in the spring and fall and a nadir in the winter. Emergency department charges of $21.2 billion were generated during the 4 years studied. While volume of visits decreased during the study, associated charges rose by 1.21%. Conclusions: Pediatric upper extremity injuries place burden on the economy of the US health care system. Types of injuries and anticipated payers vary among age groups, and while total yearly visits have decreased over the study period, the average cost of visits has risen.     

Predictors of postoperative emergency department visits after laparoscopic bariatric surgery

BackgroundPostoperative emergency department (ED) visits are a quality metric for bariatric surgical programs. Predictive factors of ED visits that do not result in readmission are not clear.ObjectivesWe aimed to identify predictors of ED visits in patients without readmission after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.MethodsThe MBSAQIP database was queried for patients who underwent LSG and LRYGB from 2015 through 2017. Patients were grouped by those who presented to the ED (ED group) and those who did not. ED visits analyzed included only those that did not result in readmission. Multivariable forward selection logistic regression was used to report adjusted odds ratios (AORs) with 95% CIs for ED visits.ResultsOf 276,073 patients, 257,985 (93.4%) were in the group who did not present to the ED, and 18,088 (6.6%) were in the ED group. Most underwent LSG (71.9%) versus LRYGB (28.1%). Multivariable forward logistic regression identified outpatient treatment for dehydration (AOR, 22.26; 95% CI, 21.30–23.27; P < .001) as the most predictive factor of an ED visit, followed by urinary tract infection (AOR, 7.25; 95% CI, 6.22–8.46; P < .001), wound disruption (AOR, 4.63; 95% CI, 3.09–6.96; P < .001), and surgical site infection (AOR, 3.80; 95% CI, 3.38–4.28; P < .001).ConclusionsPostoperative complications were the strongest predictors of ED visits after laparoscopic bariatric surgery. Quality improvement initiatives should target these variables to decrease postoperative ED visits.     

Disparities in follow-up care for ballistic and non-ballistic long bone lower extremity fractures

ObjectivesTo describe differences in follow-up compliance and emergency department (ED) visits between ballistic and non-ballistic operative lower extremity fracture patients.DesignRetrospective study.SettingUrban level 1 trauma center.Patients/ParticipantsPatients age ≥18 years with ≥1 tibia or femur fractures treated with ORIF or intramedullary nailing (IMN) between September 1, 2013 and August 31, 2015.Main Outcome MeasureA compliance fraction calculated as ([number of attended follow-up visits] / [number of attended follow-up visits + number of missed follow-up visits]) and ED visits in the post-operative period.Results612 patients were studied. Patients with ballistic lower extremity fractures had a younger mean age (30.8 years v. 41.6 years; p < 0.0001); a shorter length of stay (5.00 days v. 8.00 days; p < 0.0001); and were more likely to be male (92.6% v. 68%; p < 0.0001) and African-American (90.1% v. 63.1%; p < 0.0001) when compared to non-ballistic long bone injuries. Increased follow-up compliance (defined as a compliance fraction ≥0.75) was associated with having a non-ballistic fracture (OR 1.73, 1.13–2.64; p = 0.01), not having an ED visit (OR 2.08, 1.30–3.33; p = 0.002), and being female (OR 1.82, 1.27–2.61; p = 0.001). Increased ED utilization (≥ 1 ED visit) was associated with ballistic mechanism (OR 1.95, 1.20–3.16; p = 0.006), a low follow-up compliance fraction (OR 2.08, 1.30–3.33; p = 0.0019), homelessness (OR 3.91, 1.53–9.98; p = 0.006), and African-American race (OR 2.26, 1.26–4.05; p = 0.05). Scheduling a specific follow-up visit on the discharge summary did not predict higher compliance (OR 1.51, 0.98–2.33; p = 0.06). Conversely, the lack of a specific follow-up visit scheduled on the discharge summary did not predict ED utilization (OR 0.63, 0.34–1.17; p = 0.14).ConclusionThe results of this study demonstrate that increased utilization of the ED was associated with ballistic fractures, homelessness, decreased clinic compliance, and African American race. Furthermore, patients with non-ballistic injuries, women, and those without any ED visit were more likely to have higher outpatient clinic compliance.     

Neighborhood risk: Socioeconomic status and hospital admission for pediatric burn patients

BackgroundBurn injury continues to cause significant morbidity and mortality in the US pediatric population. Many studies using inpatient samples have found a relationship between low socioeconomic status (SES) and burn injury. The purpose of our study was to evaluate the association between SES and the likelihood of admission for Emergency Department (ED) visits for pediatric burn injury.Study designA retrospective database review of pediatric ED visits for burn injury from a statewide hospital system, from January 1, 2005 to December 31, 2014. SES was assigned using an eight factor Neighborhood Risk Index (NRI) created from census block group data, with a higher score indicative of lower SES. The outcome measure was ED visits admitted to inpatient care.ResultsWe analyzed a sample of 1845 pediatric ED visits for burn injuries. Most visits were discharged from the ED (88.4%) while 10.5% were admitted to inpatient care and 1.0% were transferred to another hospital. In a multivariable logistic regression model, patients from high risk areas (>75th percentile NRI) had 1.58 higher odds of inpatient admission compared to patients from low risk areas (<75th percentile NRI; 95% CI: 1.08–2.30), after adjusting for age, gender, ethnicity, distance to the hospital, and previous ED visit for burn injury in the past 30 days. In addition, for every 1-mile increase in distance, a child’s likelihood of admission increased by 6% (95% CI: 4–9%).ConclusionsChildren with a burn injury from the highest risk socioeconomic areas in Rhode Island had a higher likelihood of inpatient admission. Further research is needed to determine what factors associated with socioeconomic status impact this finding.     

Hospitalizations and emergency department visits in heart failure patients after bariatric surgery

BackgroundHeart failure is a disease with significant healthcare utilization and a prioritized target for readmission prevention. Although obesity is related to heart failure morbidity, the effects of bariatric surgery in obese patients with heart failure are not well studied.ObjectivesTo evaluate the impact of bariatric surgery on hospital-based healthcare utilization for patients with heart failure.SettingAdministrative statewide database.MethodsThe New York Statewide Planning and Research Cooperative System database was used to identify patients with obesity and heart failure who underwent bariatric surgery from 2005 to 2015. Emergency department (ED) visits and hospitalization records from 1 year presurgery and up to 2 years postsurgery were compared.ResultsOur study identified 899 patients with heart failure who underwent bariatric surgery. In the year presurgery, 11.48% of patients had any ED visit or hospitalization with a primary diagnosis of heart failure. The rate decreased drastically in the first year after surgery, with only 3.70% of patients having any heart failure–related hospital visits. The rate of heart failure–related visits was also lower in the second year postsurgery (3.44%) compared with the year before surgery. The risk of heart failure–related hospital visits was lower in both the first year (odds ratio [OR], .29; 95% confidence interval [CI], .19–.43) and second year postsurgery (OR, .26; 95% CI, .17–.41; P < .0001) than in the year before surgery.ConclusionsThese findings suggest that bariatric interventions might be associated with decreased risks of ED visits or hospitalizations due to heart failure exacerbations in obese patients with preexisting heart failure.     

The effect of standardized discharge instructions after gastrostomy tube placement on postoperative hospital utilization

Background/PurposeGastrostomy tube (GT) placement is a common pediatric procedure with high postoperative resource utilization. We aimed to determine if standardized discharge instructions (SDI) reduced healthcare utilization rates.MethodsWe performed a retrospective cohort study comparing postoperative hospital utilization of patients who underwent initial GT placement pre- and post-SDI protocol implementation from 2014–2019. Statistical analyses included Chi-square tests, multivariable adjusted logistic regression, adjusted Cox proportion hazard regression, and adjusted Poisson regression models when appropriate.Results197 patients were included, 102 (51.8%) before and 95 (48.2%) after protocol implementation. On primary analysis, SDI patients did not have significantly different total postoperative hospital utilization events at 30-days (48.0% vs. 38.9%, p = 0.25). On secondary analysis, SDI patients had lower rates of ED (8.4% vs. 19.6%, p = 0.026) and office visits (11.6% vs. 25.5%, p = 0.017) at 30-days. Non-SDIs patients had greater odds of ED visits (OR2.7, 95%CI 1.3–5.9, p = 0.01), office visits (OR3.7, 95%CI 1.7-8.1, p = 0.001) and phone calls (OR2.6, 95%CI 1.2–5.7, p = 0.016) at 1-year. The adjusted hazard ratio was 2.0 (95%CI 1.4–3.0, p < 0.001). Incident rate ratio were 1.8 (95%CI 1.2–2.5, p = 0.002) at 30-days and 1.9 (95%CI 1.5–2.4, p < 0.001) at 1-year post-discharge.ConclusionsSDIs post-GT placement may reduce multiple aspects of postoperative hospital utilization.     

Cystic fibrosis related diabetes in Europe: Prevalence,risk factors and outcome; Olesen et al

BackgroundCystic fibrosis related diabetes (CFRD) has implications for morbidity and mortality with several risk factors identified. We studied the epidemiology of CFRD in the large dataset of the European Cystic Fibrosis Society Patient registry.MethodsData on CF patients were investigated for the prevalence of CFRD as well as for any association with suggested risk factors and effects.ResultsCFRD increased by approximately ten percentage points every decade from ten years of age. Prevalence was higher in females in the younger age groups. CFRD was associated with severe CF genotypes (OR = 3.11, 95%CI: 2.77–3.48), pancreatic insufficiency (OR = 1.46, 95%CI: 1.39–1.53) and female gender (OR = 1.28, 95%CI: 1.21–1.34). Patients with CFRD had higher odds of being chronically infected with Pseudomonas aeruginosa, Burkholderia cepacia complex and Stenotrophomonas maltophilia than patients without CFRD, higher odds of having FEV1% of predicted <40% (OR = 1.82, 95%CI: 1.70–1.94) and higher odds of having BMI SDS ≤−2 than patients without CFRD (OR = 1.24, 95%CI: 1.15–1.34).ConclusionsSevere genotype, pancreatic insufficiency and female gender remain considerable intrinsic risk factors for early acquisition of CFRD. CFRD is associated with infections, lower lung function and poor nutritional status. Early diagnosis and aggressive treatment of CFRD are more important than ever with increasing life span.     

Dexmedetomidine reduces postoperative pain and speeds recovery after bariatric surgery: a meta-analysis of randomized controlled trials

BackgroundDexmedetomidine in opioid-sparing analgesia promotes enhanced recovery and improves postoperative outcomes.ObjectivesThis study aimed to explore the safety and efficacy of dexmedetomidine in bariatric surgery.SettingMeta-analysis.MethodsWe selected studies from Pubmed, Embase, Web of Science, and the Cochrane Central Registry of Controlled Trials before 20 April, 2021. The primary outcomes were pain scores and intravenous morphine equivalents (IVME) in the post anesthesia care unit (PACU) and postoperative day 1 (POD1). The secondary outcomes included postoperative nausea and vomiting (PONV), the length of hospital stay (LOS), intraoperative mean arterial pressure (MAP) and heart rate (HR).ResultsWe extracted 697 participants from 10 randomized controlled trials. Dexmedetomidine reduced PACU pain scores (MD = ?1.51, 95% confidence interval [CI]: ?2.60 to ?.42) after bariatric surgery, especially laparoscopic Roux-en-Y gastric bypass (MD = ?3.05, 95%CI: ?3.77 to ?2.33), but it did not affect POD1 pain scores (MD = .20, 95%CI: ?.85 to 1.26). Dexmedetomidine can reduce PACU IVME (MD = ?4.29, 95%CI: ?6.59 to ?1.99), but does not reduce POD1 IVME (MD = ?.36, 95%CI: ?2.41 to 1.68). In addition, dexmedetomidine significantly reduced PONV both in PACU (OR = .28, 95%CI: .14–.54) and POD1 (OR = .24, 95%CI: .14–.4), shortened LOS (MD = ?.29, 95%CI: ?.49 to ?.10), and had little effect on intraoperative MAP (MD = ?6.64, 95%CI: ?9.52 to ?3.76) and HR (MD = ?4.8, 95%CI: ?11.55 to 1.94).ConclusionIn conclusion, the use of dexmedetomidine in opioid-sparing analgesia contributes to postoperative analgesia after bariatric surgery, but the heterogeneity was high. In addition, dexmedetomidine is beneficial for enhanced recovery.     

Adult-to-adult living donor liver transplantation in acute liver failure

BackgroundLiving Donor Liver Transplantation(LDLT) in acute liver failure(ALF) patients has been limited by concerns regarding donor safety, consent process and recipient outcomes. Our objective was to conduct a systematic review(SR) and meta-analysis to address the concerns about subpar LDLT outcomes in patients with ALF.MethodsWe retrieved a total of 5965 literature references in our SR. United Network for Organ Sharing (UNOS) database was queried for patients over the age of 18, who underwent LDLT for “status 1” or “status 1A” listing.ResultsOf 427 articles reviewed, 3 studies comprising 2574 patients (192 underwent LDLT and 2382 DDLT), were included in the meta-analysis. One, 3,5-year patient and graft survival demonstrated no difference between LDLT and DDLT group: 1-year patient survival OR1.51; 95%CI [0.58,1.90]; 1-year graft survival OR 1.19; 95%CI [0.65–2.18]; 3-year patient survival OR 0.97;95%CI [0.52–1.88]; 3-year graft survival OR 1.21 95%CI [0.67–2.16]; 5-year patient survival 0.9; 95%CI [0.37–2.20]; 5-year graft survival OR 1.30; 95%CI [0.57–2.97]. UNOS database search returned only 3 patients that underwent LDLT for ALF compared to 1562 with DDLT, precluding comparison.ConclusionOne, 3, and 5-year patient and graft survival following LDLT vs DDLT transplantation were not statistically significantly different; however, due to limited number of studies further studies are warranted.     

Racial,ethnic and socioeconomic disparities in diagnosis,treatment, and survival of patients with breast cancer

BackgroundThe objective of this study was to determine the influence of race/ethnicity and socioeconomic status (SES) on breast cancer outcomes.MethodsA retrospective analysis was performed of Non-Hispanic Black (NHB), Non-Hispanic White (NHW), and Hispanic patients with non-metastatic breast cancer in the SEER cancer registry between 2007 and 2016.ResultsA total of 382,975 patients were identified. On multivariate analysis, NHB (OR 1.18, 95%CI: 1.15–1.20) and Hispanic (OR 1.20, 95%CI: 1.17–1.22) patients were more likely to present with higher stage disease than NHW patients. There was an increased likelihood of not undergoing breast-reconstruction for NHB (OR 1.07, 95%CI: 1.03–1.11) and Hispanic patients (OR 1.60, 95%CI 1.54–1.66). NHB patients had increased hazard for all-cause mortality (HR: 1.13, 95%CI 1.10–1.16). All-cause mortality increased across SES categories (lower SES: HR 1.33, 95%CI 1.30–1.37, middle SES: HR 1.20, 95%CI 1.17–1.23).ConclusionsThis population-based analysis confirms worse disease presentation, access to surgical therapy, and survival across racial, ethnic, and socioeconomic factors. These disparities were compounded across worsening SES and insurance coverage.     

Reasons and Risk Factors for Emergency Department Visits After Primary Total Knee Arthroplasty: An Analysis of 1.3 Million Patients

BackgroundWell-powered studies investigating the relationship of emergency department (ED) visits and total knee arthroplasty (TKA) are limited. Therefore, the specific aims of this study were to: 1) compare patient demographics of patients who did and did not have an ED visit; and for the visits, identified: 2) leading reasons; and 3) risk factors for ED visits (prearthroplasty/postarthroplasty).MethodsPatients undergoing primary TKA who had an ED visit within 90 days after their index procedure were identified from a nationwide database. The query yielded 1,364,655 patients who did (n = 5689) and did not have (n = 1,358,966) an ED visit. Baseline demographics such as age, sex, and comorbidity prevalence between the two cohorts; reasons for ED visits; and prearthroplasty and postarthroplasty risk factors were analyzed. Odds ratios (ORs) of ED visits were assessed using multivariate binomial logistic regression analyses. A P-value less than 0.001 was considered statistically significant.ResultsPatients who did and did not have ED visits differed with respect to age (P < .0001) and mean Elixhauser Comorbidity Index scores (9 vs 6, P < .0001). Musculoskeletal etiologies were the most common reason for ED visits. Hypertension was the greatest contributor to ED visits prearthroplasty and postarthroplasty. Comorbid conditions associated with ED visits postarthroplasty included peripheral vascular disease (OR: 1.61, P < .0001), coagulopathy (OR: 1.58, P < .0001), and rheumatoid arthritis (OR: 1.56, P < .0001).ConclusionBy identifying demographic patterns of patients, reasons, and risk factors, the information found from this study can help identify targets for quality improvement to potentially reduce the incidence of ED visits after primary TKA.     

Incidence and mechanism of injury of clavicle fractures in the NEISS database: Athletic and non athletic injuries

BackgroundClavicle fractures are a very common injury due to accidental trauma, specifically during athletics. The purpose of this study was (1) to determine the incidence of clavicle fractures presenting to United States emergency departments; (2) to compare the rate of clavicle injuries from 2012 to 2015 to 2002–2005 (3) to determine the most common mechanisms of injury for clavicle fractures.MethodsThe National Electronic Injury Surveillance System (NEISS) was queried for the years 2002–2005 and 2012–2015. Examined variables included patient age, sex, and year of admission. Total annual case numbers were estimated using NEISS hospital weights. Annual injury incidence rates by age group and patient sex were calculated based on yearly U.S. Census estimates. Chi square test and logistic regression were used to compare injury rates by sex and age groups. Statistical significance was set at P < 0.05.ResultsDuring the 8 years studied, the participating emergency departments (EDs) coded 14,795 fracture exposures. Using weighted estimates, this represent 545,663 injuries nationally (95% CL 425,986–665,339). This resulted in an incidence of 22.4 injuries per 100,000 person years (95% CL 17.5–27.3). The most common causes of injury were bicycles (15.1%), football (10.7%), beds/bedframes (6.8%), stairs (5.4%), and floors (4.0%). Fifty percent of clavicle fractures were due to an athletic activity. There was no significant change in injuries from 2002 to 2005 compared to 2012–2015 (23.1 per 100,000, 95% CL 18.5–27.7, and 22.4 per 100,000 person years (95% CL 17.5–27.3), respectively).ConclusionClavicle fractures continue to occur at similar rates, with athletics accounting for 50% of injuries. Patients most at risk for clavicle fracture was bimodal in nature, with males aged 0–19 being the most common. Females were most at risk between 0 and 9 years old. We found that clavicle fracture continued to occur at similar rates as compared to 10 years prior, especially in active populations participating in collision sports (bicycle, football, and soccer).     

Children after motor vehicle crashes: Restraint utilization and injury severity

BackgroundAlthough injury patterns after motor vehicle crashes (MVCs) are well documented, association between adequate restraint and injury severity is unclear. We aimed to determine if improper restraint affects injury rates and severity.MethodsA retrospective chart review of 477 children hospitalized in Pediatric Trauma Center after MVC was performed. Injuries in various age groups (0–7, 8–12, 13–16, 17–18 years) with different restraint quality measures (proper [PR] and improper/unrestrained [IUR]) as well as injury severity score (ISS: mild [1–9], moderate [10–15], severe [16–25], and profound [> 25]) were evaluated and compared. Chi-square and Wilcoxon rank-sum tests were used for statistics.ResultsIn all age groups head/neck injuries were most common (55–63%), while abdominal and pelvic injuries were least likely except group 8–12 years where abdominal injuries ranked third (17.1%). Overall, 64.5% had PR and 35.5% IUR. Interestingly, that greatest proportion of IUR was in the youngest age group (0–7). It decreased with aging and children aged 17–18 years were significantly less likely to be IUR compared to those 0–7 years (OR[odds ratio] = 0.58; 95%CI[confidence interval] 0.35–0.94). We did not find significant differences in rates of various injuries between PR and IUR. However, ISS severity in IUR was significantly greater than in PR (median with interquartile range 6(2–14) and 5(1–9), respectively; P = 0.001). As a result, IUR compared to PR were less likely to have mild ISS (OR = 0.6, 95%CI 0.39–0.90) but more likely to have profound ISS (OR = 3.3, 95%CI 1.48–7.43).ConclusionRestraint quality has significant impact on injury severity in children after MVC.Level of EvidenceLevel III.     

Effect of an intervention for patients 65 years and older with blunt chest injury: Patient and health service outcomes

IntroductionBlunt chest injury in older adults, aged 65 years and older, leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes in older adults with blunt chest injury.MethodsChIP comprised multidimensional implementation guidance in three key pillars of care for blunt chest injury: respiratory support, analgesia, and complication prevention. Implementation was guided using the Behaviour Change Wheel. This proof-of-concept controlled pre- and post-test study with two intervention and two control sites in Australia was conducted from July 2015 to June 2019. The primary outcomes were non-invasive ventilation (NIV) use, unplanned Intensive Care Unit (ICU) admissions, and in-hospital mortality. Secondary outcomes were health service and costing outcomes.ResultsThere were 1122 patients included in the analysis, with 673 at intervention sites (331 pre-test and 342 post-test) and 449 at control sites (256 pre-test and 193 post-test). ChIP was associated with unplanned ICU admissions and in NIV use with a reduction of the odds in the post vs the pre periods in the intervention sites when compared to the controls (ratio of OR=0.13, 95%CI=0.03-0.55) and (ratio of OR=0.14, 95%CI=0.02-0.98) respectively. There was no significant change in mortality. Implementing ChIP was also associated with health service team reviews with an increased odds in the post vs pre periods in the intervention sites in comparison to the controls for surgical review (ratio of OR =6.93, 95%CI=4.70-10.28), ICU doctor (ratio of OR =5.06, 95%CI=2.26-9.25), ICU liaison (ratio of OR =14.14, 95%CI=3.15-63.31), and pain (ratio of OR =5.59, 95%CI=3.25-9.29). ChIP was also related to incentive spirometry (ratio of OR=6.35, 95%CI= 3.15-12.82) and overall costs (ratio of mean ratio=1.34, 95%CI=1.09-1.66) with a higher ratio for intervention sites.ConclusionImplementation of ChIP using the Behaviour Change Wheel was associated with reduced unplanned ICU admissions and NIV use and improved health care delivery.Trial registrationANZCTR: ACTRN12618001548224, approved 17/09/2018     

Oncological outcomes of salvage radical prostatectomy for recurrent prostate cancer in the contemporary era: A multicenter retrospective study

BackgroundSalvage radical prostatectomy (sRP) historically yields poor functional outcomes and high complication rates. However, recent reports on robotic sRP show improved results.Our objectives were to evaluate sRP oncological outcomes and predictors of positive margins and biochemical recurrence (BCR).MethodsWe retrospectively collected data of sRP for recurrent prostate cancer after local nonsurgical treatment at 18 tertiary referral centers in United States, Australia and Europe, from 2000 to 2016. SM and BCR were evaluated in a univariate and multivariable analysis. Overall and cancer-specific survival were also assessed.ResultsWe included 414 cases, 63.5% of them performed after radiotherapy. Before sRP the majority of patients had biopsy Gleason score (GS) ≤7 (55.5%) and imaging negative or with prostatic bed involvement only (93.3%). Final pathology showed aggressive histology in 39.7% (GS ≥9 27.6%), with 52.9% having ≥pT3 disease and 16% pN+. SM was positive in 29.7%. Five years BCR-Free, cancer-specific survival and OS were 56.7%, 97.7% and 92.1%, respectively. On multivariable analysis pathological T (pT3a odds ratio [OR] 2.939, 95% confidence interval [CI] 1.469–5.879; ≥pT3b OR 2.428–95% CI 1.333–4.423) and N stage (pN1 OR 2.871, 95% CI 1.503–5.897) were independent predictors of positive margins. Pathological T stage ≥T3b (OR 2.348 95% CI 1.338–4.117) and GS (up to OR 7.183, 95% CI 1.906–27.068 for GS >8) were independent predictors for BCR. Limitations include the retrospective nature of the study and limited follow-up.ConclusionsIn a contemporary series, sRP showed promising oncological control in the medium term despite aggressive pathological features. BCR risk increased in case of locally advanced disease and higher GS. Future studies are needed to confirm our findings.     

Determining the incidence of postbariatric surgery emergency department utilization: an analysis of a statewide insurance database

BackgroundPrior studies have found rates of emergency department (ED) visits after bariatric surgery approach 15% with the majority (>60%) not requiring admission. The timeframe for which ED utilization remains elevated postoperatively remains unknown. We hypothesize that ED utilization following bariatric surgery remains elevated for months after surgery with the majority of visits not requiring admission.ObjectiveNo study has determined the impact bariatric surgery has on health care resource utilization in the two years following surgery. The aim of this study is to determine the frequency of ED visitation in the 2 years following bariatric surgery.SettingsDatabase study, single state-wide insurance database.MethodsWe queried the Colorado All Payers Claim Database. Patients with data 1 year before and 2 years after surgery were included. Primary outcomes of interest were ED visits or readmissions during the 2-year period. Bariatric surgeries were identified using CPT codes. Diagnoses for an ED visit or readmission were determined by ICD codes.ResultsA total of 5399 patients underwent bariatric surgery from January 2013–November 2017. Of these, 59% underwent sleeve gastrectomy, 38% Roux-en-Y, 2% gastric band, and 1% another surgery. Median age was 44 (IQR 35–54) years, and 82% were female. Overall, 3103 patients (57%) visited the ED at least once with a total of 12,988 visits, 1267 of which (9.8%) resulted in admission. ED use was highest in the 30 days following surgery (17%) but remained above presurgery baseline for 8 months (7.4% at 8 mo compared with baseline mean 6.4% [95% CI 6.0%–6.8%]).ConclusionsED visits remain elevated for 8 months post bariatric surgery with over 90% of visits not requiring an admission. Interventions that prevent emergency department utilization should be key focus of quality improvement projects to limit health care resource utilization following bariatric surgery.     

Inequalities in the risk of disability due to traffic injuries in the Spanish adult population, 2009–2010

BackgroundAlthough traffic injuries (TIs) are an important cause of disability the related factors are little known. We aimed to estimate the differences in risk of TI-related disability according to individual characteristics that might generate health inequalities.MethodsCross-sectional study using a representative Spanish population sample drawn from the European Health Interview Survey 2009/2010. We calculated traffic crashes in the preceding year which resulted in injuries. Disability was measured using the Global Activity Limitation Indicator and four indicators of limitations (sensory, physical functional, self-care and domestic activities). Principal socio-demographic and behavioural/lifestyle variables were studied. We used multivariate logistic regression to estimate the risk (ORs) of TI-related disability in the sample as whole and disability-related factors in persons who had experienced TIs.ResultsPersons with TIs had a higher risk of global disability (OR = 1.61; 95%CI:1.17–2.20), physical functional limitations (OR = 1.96; 95%CI:1.33–2.89) and self-care limitations (OR = 1.73; 95%CI:0.98–3.05). Among persons with TIs, GALI-related risk was higher in women (OR = 3.06, p = 0.002) and persons aged over 30 years (OR_31–45years = 6.81, p < 0.001; OR_46–64years = 5.96, p = 0.011; OR_>64years = 4.54, p = 0.047). Lower risk was observed among persons with a higher educational level (OR = 0.22, p = 0.003). The risk of disability among persons with TIs who consumed illegal drugs was OR = 3.9 (p = 0.023).ConclusionsTraffic injuries in the preceding year are associated with higher risk of disability, which is unevenly distributed. Individual (women and persons over 30 years), socio-economic (lower educational level) and behavioural (illegal drug use) factors are involved. Actions aimed at changing the unequal risk among vulnerable subgroups and providing health, social and protective services should be implemented.     

Thoracolumbar spinal fractures associated with ground level falls in the elderly: An analysis of 254,486 emergency department visits

Study designretrospective.ObjectivesTo investigate the epidemiology of elderly (age ≥65 years) patients who presented to the emergency department (ED) in the United States with thoracolumbar (TL) fractures after ground level falls.MethodsUsing the National Emergency Department Sample database, we queried all ED visits in the United States from 2009 through 2012 of elderly patients who presented after ground level falls. We identified patients who sustained TL fractures with and without neurological injury. Resulting data was used to analyze the fracture prevalence, ED and patient characteristics, associated injuries, treatment patterns, inpatient mortality, and hospital charges.ResultsOf the 6,654,526 ED visits in the elderly for ground level falls, 254,486 (3.8%) were associated with a diagnosis of TL fracture. 39% patients had multiple injuries, and upper extremity fractures were the most common associated injuries. Overall, 55.6% were admitted to the hospital. Of those, 77.7% were treated non-operatively, 20.4% were treated with cement augmentation alone, 1.5% were treated with spinal fusion surgery, and 0.4% were treated with spinal decompression alone. The overall rate of inpatient mortality was 2.14%.ConclusionsThis investigation evaluated the epidemiology of elderly patients who presented to the ED in the United States with TL fractures after ground level falls. The study demonstrated a rather high incidence of TL fractures in this patient cohort. As a result, it is important for ED physicians and orthopaedic surgeons to be highly suspicious of TL fractures in elderly patients who sustain low energy trauma. With the continued aging of the population and rising health care costs, future effort ought to focus on fall prevention and increased surveillance for TL injuries in the elderly.