Faculty Bibliography

Purpose of Review: Sleeve gastrectomy has become one of the most common bariatric surgical procedures world-wide. The complication rate overall is low, but staple line leak remains one of the most morbid and difficult to manage complications. The management of staple line leaks has evolved over time and now several non-operative, endoscopic, and surgical options exist with varying rates of success. Recent Findings: Based on the available data some interventions appear to be more efficacious than others, and modern management has moved towards a core set of practices. Endoscopic interventions may help many patients avoid operative intervention. Importantly, many patients may require repeated and varying interventions to fully resolve their leak. Summary: Each case should be managed by a multidisciplinary team with the interventions chosen based on patient factors, leak characteristics, and institutional capabilities. Nutritional optimization remains paramount to promote healing regardless of the interventions used.

Our study aimed to identify prognostic factors for surgical site infection following long bone fracture intramedullary nailing at a tertiary hospital in a low-resource setting. This was a longitudinal observational study involving 132 participants enrolled over a one-year period with femoral and tibial diaphyseal fractures scheduled for ORIF. Participant median age was 30 years (range: 26 - 42). The prevalence of surgical site infection was 16%. Male sex (AOR=0.26, 95% CI [0.70-0.98]; p = 0.047) was associated with lower odds of surgical site infection while associated non-musculoskeletal injuries were associated with higher odds of developing surgical site infection. Our study confirms a higher surgical site infection rate than normally accepted. However, intramedullary nailing in our setting is justified as it allows an early return to a pre-injury state. These interventions must be carried out in the best possible circumstances. Future studies could explore alternative methods of fracture fixation.

BACKGROUND:The mangled extremity (ME) is a limb with a multisystem injury (soft tissue, bone, nerves, or vessels). We hypothesized that trauma patients who present with mangled lower extremities (ME) experience a higher rate of venous thromboembolism when matched against trauma patients of similar injury burden without ME. MATERIALS AND METHODS/METHODS:Data were abstracted from the Trauma Quality Improvement Program database from 2013 to 2016. Baseline comparisons were made between patients with and without ME. Propensity score matching with logistic regression modeling on the matched sample was performed controlling for patient gender, race, insurance status, age, injury severity score, Charlson comorbidity index, presence of significant other non-ME trauma, use of and time to prophylactic anticoagulation, placement of an inferior vena cava filter, and if immediate operative intervention was performed. RESULTS:A total of 1060 patients presented with an ME. Compared with other trauma patients, those with ME tended to be younger and male. They were more likely to receive prophylactic anticoagulation and an inferior vena cava filter. After propensity score matching, ME was statistically significantly associated with pulmonary embolism (PE) but not deep venous thrombosis (average treatment effect on the treated 1.7%, P = 0.04; and 1.4%, P = 0.22, respectively). These results were confirmed in a logistic regression on the matched sample (odds ratios 1.6, P = 0.11 for deep venous thrombosis, and odds ratio 3.2, P = 0.006 for PE). CONCLUSIONS:Patients with mangled lower extremities experience higher rates of PE. Based on these findings, institutions may consider evaluating their own VTE rates and chemoprophylaxis protocols in those with MEs.

Introduction: Increasing evidence suggests that disparities in outcomes exist among patients with traumatic brain injury (TBI), but much less is known about such disparities in the elderly. The objective of this study was to determine if race and insurance status are associated with mortality among elderly patients with isolated moderate and severe TBI.
Method(s): A 4-year retrospective analysis of the Trauma Quality Improvement Program database (2013-2016) was performed to identify patients aged 60 and older with isolated moderate or severe TBI. Patients were stratified by race and insurance status comparing demographic characteristics and outcomes. A logistic regression analysis was performed to determine the relationship between race, insurance status, and mortality among elderly patients with isolated moderate and severe TBI.
Result(s): A total of 27,951 patients with isolated TBI were identified. Of those, 7.8% were black with 50.2% having insurance and 79.5% were white with 45.3% having insurance. The overall mortality rate was 9.22% with no significant differences in Head AIS. Black patients with insurance were significantly older (73 vs 63, p<0.001) and had more comorbidities (1 [0,2] vs 0 [0,1], p=0.002) when compared with black patients without insurance. With the exception of age, no significant differences were found among white patients. After adjusting for confounding variables, black race was independently associated with decreased mortality (AOR 0.69, 95% CI 0.5-0.96, p= 0.016).
Conclusion(s): Black race, independent of insurance, is associated with decreased mortality among older adults with isolated moderate and severe TBI. The role of race in affecting mortality following TBI warrants further investigation.
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BACKGROUND: Surgery is a vital component of a comprehensive health system, but there are often personnel limitations in resource constrained areas. Zambia provides post graduate surgical training through two systems to help address this shortage. However, no studies have analyzed surgical trainees' perceptions of these programs. METHODS: Surgical registrars at COSECSA affiliated hospitals in Zambia were surveyed about their programs. Responses were analyzed to identify key strengths and challenges across several categories including: operative training, clinical training, educational experiences, and career plans. RESULTS: Registrars report having significant independence and receiving broad and high quality operative training. They note specific challenges including limitations in specialty training, resources, and infrastructure. CONCLUSIONS: Zambian training programs have the potential to increase number of surgeons in Zambia by a significant amount in the coming years. These programs have many strengths but also face challenges in their goal to expand surgical access in the country.

Purpose: There is a significant variation in the MELD scores and subsequent morbidity among liver recipients in the US. Larger OPOs consistently serve patients with advanced disease. Previous studies have shown 2.5 times greater prevalence of transplanted patients with MELD ³ 24 in these OPOs. CMS recent reimbursement adjustments may disproportionately affect certain programs given their increased prevalence of patients with more advanced disease. Methods: We analyzed the prevalence of transplants among patients with high UNET MELD scores and associated charges, costs, and reimbursements. We compared low, medium and high MELD score groups. Between 2014-2015, 43 liver transplants, all with >30 days survival, were analyzed. Results: Only 2 had MELD scores below 25 at transplant, both of which from live donors. 95% of patients had MELD scores above 25 and among these, 18% had MELD 40 or were Status 1. Compared to the national average, our MELD scores were: 25% 21-30 (National 21.5%, p >0.05), 70.5% 31-40 (National 25.9%, p < 0.001), and 4.5% Status 1 (National 5.9%, p >0.05). For MELD scores 21-30, hospital charges averaged $645,214 and reimbursements were $150,706. For MELD scores 31-39, charges were $686,720, and reimbursement were $139,776. Reviewing MELD 40/ Status 1 patients, the average hospital charges and reimbursements were $1,136,813 and $293,776 respectively. We compared their amounts to the MELD 40 patients who had hospital charges of $625,371 and reimbursements of $142,051 respectively. This demonstrated a loss of $843,037 for the first group and $483,320 for the second. Length of stay was 32 days for MELD 40/ Status 1 and 8 days for MELD 40 (p < 0.000). Conclusion: ³ 40 MELD patients have a huge financial impact on institutions. The difference between 25-39 and ³40 MELD points is greater than half a million dollars. These data reflect and include dialysis, intubation and ICU stay but do not include rehabilitation expenses which will be the focus of another study. We find that our institution, which likely reflects many institutions in our OPO, serves sicker patients and therefore incurs higher costs but receives lower reimbursements, as they are based on national expected care costs for healthier patients. A broader sharing in the US may equalize costs. Payers should take into account the added financial burden of performing transplant in high MELD patients

An understanding of the burden of skin disease in the uninsured population is needed to address the unique barriers they face to access dermatologic care. We conducted a retrospective chart review of patients seen for skin conditions over three years at the New York City (NYC) Free Clinic, a weekly primary care clinic operated by the NYU School of Medicine and the Institute for Family Health. Main outcomes of this study were descriptive analyses of demographic characteristics, diagnoses, management strategies, and referral outcomes, as well as key factors influencing referral to a dermatologist and referral attendance. Diagnosis was a significant predictor of referral (p<.000). The referral attendance rate was 52.5%. Patients older than 50 years were more likely to attend their appointments than younger patients (p=.025). Gender, wait time, and travel distance had no significant association with non-attendance. While demand for dermatologic care by uninsured patients in NYC is high, referral non-attendance remains a substantial barrier to care.

This paper presents results from a pilot study of the synergies between the opportunity costs incurred by research participants, participant compensation, and program attendance in a family-based substance use and HIV preventive intervention for Hispanic adolescents in Miami-Dade County, Florida. To estimate parent/caretaker cost per session and cost for the duration of the intervention, we administered the Caretaker Drug Abuse Treatment Cost Analysis Program to a random sample of 34 families who participated in a recent clinical trial of Familias Unidas. The total opportunity cost per parent/caretaker was under $40 per group session, under $30 per family session, and just over $570 for the duration of the intervention. Participants were compensated between $40 and $50 per session and attended more than 79% of family and group sessions. Parents and caretakers incurred a cost of approximately $30-40 per intervention session for which they were adequately compensated. Attendance was very good overall for this group (>79%) and significantly higher than attendance in a comparable uncompensated study group from another recent Familias Unidas trial that targeted similar youth. Findings suggest that incentives should be considered important for future implementations of Familias Unidas and similar family-based interventions that target minority and low-SES populations.